Survey to Measure Interest in a Return-to-Work Seminar/Workshop

Your Work Status

Your answers to this survey will provide valuable information to help us design an educational seminar addressing the topic of returning to work for people with limb loss. All questions are optional, so you can share only as much information as you like. All information provided will be kept confidential and we will never share your data.

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* 1. Are you currently working?

Yes

If not, why not?

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* 2. If not, how long have you been out of work?

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* 3. If not, are you considering returning to work?

Yes

Maybe

What are your concerns about returning to work?

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* 4. If you have concerns about returning to work, have you been able to address your concerns satisfactorily?

Yes

Somewhat

No, not at all

Yes

Somewhat

No, not at all

Would you like to explain your answer?

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* 5. If working now, what challenges did you face or are facing now that you didn’t think you would encounter?

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* 6. How likely would you be to attend a seminar/workshop about returning to work that was tailored for individuals living with limb loss?

Very Likely

Somewhat Likely

Not At All Likely

Very Likely

Somewhat Likely

Not At All Likely

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* 7. If you would like to be contacted when a Back-to-Work seminar is scheduled, please provide your contact information.

Name

City/Town

State/Province

Email Address

Phone Number