Disability Status Survey
Please complete this survey to help us better understand disability status, needs, and experiences. Your responses are confidential and will be used to improve accessibility and support.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Do you have a disability?
*
Yes
No
Prefer not to say
If yes, what type(s) of disability do you have? (Select all that apply)
Physical disability
Sensory disability (vision, hearing, etc.)
Intellectual or developmental disability
Mental health condition
Chronic illness
Other
How would you rate the severity of your disability?
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
How does your disability impact the following areas of your life?
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Mobility
1
2
3
4
Communication
5
6
7
8
Self-care
9
10
11
12
Education/Work
13
14
15
16
Social participation
17
18
19
20
What accommodations or support do you currently receive? (Select all that apply)
Mobility aids (wheelchair, cane, etc.)
Personal assistance
Accessible materials (braille, large print, etc.)
Assistive technology
Special transportation
None
Other
Are your current accommodations sufficient?
Yes
No
Not applicable
What additional support or accommodations would help you?
How accessible do you find public spaces and services in your area?
1
2
3
4
5
Please provide any additional comments or suggestions regarding accessibility and inclusion.
Submit Survey
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