Bracknell Forest Council and NHS Berkshire are conducting an assistive technology survey to develop an assistive technology plan that supports people in living independently. The survey asks individuals about their current use of and experiences with assistive technologies like smoke detectors, falls detectors, and lifeline systems. It also seeks to understand how individuals learned about assistive technology options and whether they felt involved in the selection process. The goal is to identify both benefits and limitations of assistive technologies so the plan can best meet community needs.

1. Assistive Technology Survey6.3.12-Individual easy read 1
Bracknell Forest Council and NHS
Berkshire Joint Assistive Technology
Survey for Individuals 2012
in Easy Read

2. Assistive Technology Survey6.3.12-Individual easy read 2
What is happening?
The Council and NHS Berkshire
are putting together a Assistive Technology Plan.
This plan aims to ensure that Assistive Technology can
support and help people to live the life they want.
We would like to hear from you about your experiences.
Please fill in the survey and send to: Amina Begum at
Bracknell Forest Council Adult Social care & Health 4th
Floor, Time Square, Bracknell, RG12 1JD or email the form to:
amina.begum@bracknell-forest.gov.uk or call her on 01344
351204 for more detail.
This survey is also available on our webpage:
www.bracknell-forest.gov.uk/assistivetechnologysurvey
If you need help or support in completing this form contact our
Customer Services section on 01344 352000 and they will be
able to help you to fill the form either in person or over the
telephone.
The consultation exercise will take place from 16th
March
through to 7th
June 2012, which will include questionnaires and
workshops.

3. Assistive Technology Survey6.3.12-Individual easy read 3
What is Assistive Technology?
Assistive technology can be lots of different things
• It can be a piece of equipment that is there to help
you do something you find hard.
• It could be a bath board to help you get in and out
of the bath.
• It could be a wheelchair to help you get around.
• It could be an alarm to tell you if there is a fire.
• Or it could be an alarm that you press if you need
help

4. Assistive Technology Survey6.3.12-Individual easy read 4
Q1.Do you currently use Assistive Technology?
Q2.Please tell us what Assistive Technology you use or have
used?
Please tick everything you have
Smoke detector
Carbon monoxide detector
Falls detector
Please tick
Yes Please answer Q2
No Please answer questions on the
red pages

5. Assistive Technology Survey6.3.12-Individual easy read 5
Please tick everything you have
Property exit sensor
Bed sensor
Chair sensor
Medication dispenser
Flood detector
Bogus caller button

6. Assistive Technology Survey6.3.12-Individual easy read 6
Please tick everything you have
Temperature extreme sensor
Vibrating pillow alert
Flashing doorbell
Video door entry system
Natural gas detector
Pagers

7. Assistive Technology Survey6.3.12-Individual easy read 7
Please tick everything you have
Environmental control unit
Lifeline
Care call pendant
Movement sensor PIR
Other

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Q3.How did you find out about Assistive Technology in Bracknell
Forest?
Please tick
someone from GP surgery
someone from health or social
services
your paid carer
family member
neighbour or friend
voluntary or community
organisation
housing provider / scheme
manager
Shop mobility

9. Assistive Technology Survey6.3.12-Individual easy read 9
Please tick
websites
Publicity/leaflet
Other
Q4.Were you given choices about the Assistive Technology
equipment you could have?
Please tick
Yes
No

10. Assistive Technology Survey6.3.12-Individual easy read 10
Q5. How were you involved in making the choice about the
Assistive Technology you have?
Please tick
Did someone come to talk to you
Was it done through the
assessment?
No one told me
Other

11. Assistive Technology Survey6.3.12-Individual easy read 11
Q 6. Did they tell you about the good things about Assistive
Technology?
Please tick
Yes
No
Please give example

12. Assistive Technology Survey6.3.12-Individual easy read 12
Q7. Did they tell you about the bad things about Assistive
Technology?
Please give example
Please tick
Yes
No

13. Assistive Technology Survey6.3.12-Individual easy read 13
Q8. Were you happy with the time it took for the Assistive
Technology equipment to arrive?
Please tick
Yes
No
Please give us more information

14. Assistive Technology Survey6.3.12-Individual easy read 14
Q9. What are the good things about having Assistive
Technology?
Please tick
control in my life
live where I want
privacy when I need it
understand and manage risks to
myself and others
get out and about
feel safe in my home
get help and support when I need
it

15. Assistive Technology Survey6.3.12-Individual easy read 15
Please tick
Helps me to carry on with work
/retain my work
Keeps me out of hospital
Other
Q10. What are the bad things about having Assistive Technology?
Please tick
Batteries need to be replaced
The alarms going off at the wrong
time
Phone line out of order

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Please tick
Other
There are no bad things

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Red pages
Q11. Do you think Assistive Technology could support and help
you to live the life you want? For examples of Assistive
Technology see pages 14 & 15.
Please tick
Yes
No
more information to make a decision
I would like to talk to someone about
this

18. Assistive Technology Survey6.3.12-Individual easy read 18
Red pages
Q12. How do you think Assistive Technology could help you?
Please tick
control in my life
live where I want
privacy when I need it
understand and manage
risks to myself and others
get out and about
feel safe in my home
get help and support when I
need it
Other

19. Assistive Technology Survey6.3.12-Individual easy read 19
Q13. Is there any thing else you want to tell us
Equalities Monitoring
We know that different people have different needs and different
experiences of using services. We need to know what they are to be able
to help make a difference.
You do not have to complete this questionnaire, but it
would be very helpful to us if you do.
The information you give will be kept confidence and kept in compliance
with the Data Protection Act 1998.
Sex - Please tick “ ”
Male Female
How would you describe your religion / belief? Please tick “ ”
None
Christian (all Christian denominations)
Buddhist
Hindu
Muslim
Sikh
Jewish
Other (please specify) ________________
Which age group are you? - Please tick “ ”
18-24 25-34 35-44 45-54 55-64 65-74
75-84 85+

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How would you describe your sexual orientation?
Heterosexual/ straight
Gay man
Lesbian/ gay woman
Bisexual
Prefer not to say
As changes are made to health and social care services, we would
like to hear your views. Would like to take part in future consultation
exercises? (Please tick “ ”)
Yes No
How would you prefer we should contact you?
By post By email By telephone In person
I need large print or easy read
Please provide us with your contact details
Name ___________________________
Address __________________________
__________________________
__________________________
Email __________________________
Telephone number: _________________
Thank you for taking the time to complete this survey the
information you provide will help us to improve our
Assistive Technology Service