TBI Survivors SPEAK OUT! Questionnaire
I have developed a TBI Survivor Interview page on my blog, Surviving Traumatic Brain Injury. My interview consists of 20 questions that can be answered easily. I hope the page will provide information, inspire other TBI survivors, and connect people.
If you’d like take part in this project, please visit my site at TBI Survivors SPEAK OUT! – Questionnaire. You can copy and paste the questions and your answers into your email program and send your interview to me at email@example.com. I will do my best to publish every interview. (I will only edit obvious typos, punctuation, for clarity, and to fit the format.)
If possible, please send a photo or two (before/after) to include with your interview (optional, but preferred).
You will also need to fill out the release form so I can publish your interview on my “Surviving Traumatic Brain Injury” blog.
I, ____(FULL NAME)____, on this date (e.g., 04/01/2014), ____________, give Donna O’Donnell Figurski permission to use my interview on her “Surviving Traumatic Brain Injury” blog. (Your first and last name must be included on the Release Form, even if you do not want it posted on the web.)
Please put an “X” before the statement you agree with.
____I give Donna O’Donnell Figurski permission to use my last name.
____I do not give Donna O’Donnell Figurski permission to use my last name.
Please answer as many questions as you feel comfortable with. Your answers can be very brief; but, if long, your answer should be no more than 100 words. You may send your answers to me at firstname.lastname@example.org.
QUESTIONNAIRE for a TBI Survivor SPEAK OUT!
1. What is your name? (last name optional)
2. Where do you live? (city and/or state and/or country) Email (optional)
3. On what date did you have your brain injury? At what age?
4. How did your brain injury occur?
5. When did you (or someone) first realize you had a problem?
6. What kind of emergency treatment, if any, did you have?
7. Were you in a coma? If so, how long?
8. Did you do rehab? What kind of rehab (i.e., inpatient or outpatient and occupational and/or physical and/or speech and/or other)? How long were you in rehab?
9. What problems or disabilities, if any, resulted from your brain injury (e.g., balance, perception, personality, etc.)?
10. How has your life changed? Is it better? Is it worse?
11. What do you miss the most from your pre-brain-injury life?
12. What do you enjoy most in your post-brain-injury life?
13. What do you like least about your brain injury?
14. Has anything helped you to accept your brain injury?
15. Has your injury affected your home life and relationships and, if so, how?
16. Has your social life been altered or changed and, if so, how?
17. Who is your main caregiver? Do you understand what it takes to be a caregiver?
18. What are your plans? What do you expect/hope to be doing ten years from now?
19. Are you able to provide a helpful hint that may have taken you a long time to learn, but which you wished you had known earlier? If so, please state what it is to potentially help other survivors with your specific kind of brain injury.
20. What advice would you offer to other brain-injury survivors? Do you have any other comments that you would like to add?