Annual Questionnaire 2008; Page One of Three

In return for being granted funding by public bodies, The Post Polio Support Group is obliged to pass your contact details (i.e. name & address) and details of your needs (i.e. aids, appliances, services, therapies, etc.) to such bodies. The Post Polio Support Group may also in certain instances be requested to give such details to private individuals / organisations in the event that funding is provided by such private individuals / organisations.

We would like your permission to give these details on your behalf. In this regard, it would greatly assist us if you would grant us your permission by ticking the following boxes:

I agree that in return for being granted funding by public bodies, my needs and contact details being made available by the Post Polio Support Group to such bodies

I agree that in return for being granted funding by private individuals / organisations, my needs and contact details being made available by the Post Polio Support Group to such individuals / organisations

I agree to my contact details only being made available to the relevant PPSG representative

Please Confirm Category of Membership
Polio Survivor

Family/Carer Friend/Supporter

1. In the past 12 months have you experienced any increased difficulty in carrying out usual daily activities, e.g. walking, bathing, etc.?

None

Some Difficulty

Great Difficulty

2. Do you live in:

A city

A town

Rural Area or Townland

3. Do you live:

On your own

With dependent child(ren) under 18

With partner/family/relative(s)/carer(s)

In sheltered accommodation

4. Are your MEDICAL EXPENSES covered by (tick all that apply):

Medical Card

Long-term Illness Card

HSE Refunds

Private Health Insurance

Other (Please Specify): Other (Please Specify):

5. Are you currently:

Employed full-time

Employed part-time

Working full time in the home

Unemployed

Retired

6. Do you avail of any of the following?

Home Care Assistant

Home Help

Personal Assistant

IF YES: Is this funded:

Privately

By the HSE or other state body or other state body

By a voluntary organisation / charity

7. Please indicate which of these categories best represents your net weekly household income? (i.e. amount after deductions for tax, PRSI, mortgage, etc.)

Less than €250

€250 - €375

€375 - €500

€500 - €625

€250 - €375

€625 - €750

€750 - €875

€875 - €1000

More than €1000

8. Are you able to make ends meet?

With great difficulty

With some difficulty

Without difficulty

9.Do you have access to an adapted bathroom?

Yes

No

IF NO: Would an adapted bathroom be of assistance to you?

Yes

No

Do you intend to apply to your Local Authority for a Disabled Person’s Housing Grant?

Yes

No

(The Post Polio Support Group can provide advice and other assistance to those who would experience difficulty or hardship in having building adaptation work done. The Group will only deal with cases where an application will be made to the County or City Council for the Disabled Person’s Housing Grant.)