Chronic Illness Employment Impact Survey
Please provide information about how chronic illness has affected your employment.
Full Name
First Name
Last Name
Email Address
example@example.com
Do you have a diagnosed chronic illness?
Option 1
Option 2
Option 3
How has your chronic illness impacted your ability to work?
Have you experienced any workplace accommodations due to your illness?
Option 1
Option 2
Option 3
Please describe any accommodations you have received.
Have you faced any discrimination or challenges at work related to your illness?
Option 1
Option 2
Option 3
Please describe any discrimination or challenges faced.
Submit
Should be Empty: