Intro 

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your street address?

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* 4. In what city do you currently live in?

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* 5. In what state do you currently live in?

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* 6. Zip Code

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* 7. What is your preferred method of contact?

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* 8. Phone Number

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* 9. Email

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* 10. Date of birth.

Date

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* 11. Which of the following options most closely aligns with your gender?

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* 12. What is your ethnicity? (Please select all that apply.)

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* 13. What language(s) do you speak at home?

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* 14. Marital Status

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* 15. Are you a United States Veteran?

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* 16. What type of disability do you have?

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* 17. Would you like to disclose any other disabilities or identities that add to your intersectionality? If yes, please specify below.

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* 18. In general, how would you rate your overall mental or emotional health?

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* 19. Do you have limited or no arm function?

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* 20. Do you have limited or no hand function?

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* 21. Do you have limited or no finger function?

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* 22. If selected, will you be able to attend video meetings?

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* 23. Do you know what assistive technology would best fit your needs?

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* 24. If your answer to Question 24 was yes, please list device(s) below.

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* 25. If needed, do you have assistance with installing the assistive device(s)?  (Tech support may be made available.)

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* 26. Have you received assistance from the TSF Foundation in the past?

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* 27. Have you applied for assistance from other organizations for the technology you are requesting?

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* 28. If yes, list organization(s) below.

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* 29. How will receiving this technology improve your independence and/or quality of life? (2-5 sentences)

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* 30. If you had access to assistive technology that could provide you with the necessary tools to go back to work/continue working, how interested would you be in doing so?

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* 31. Are you a part of any disability-focused support groups, Facebook groups or online forums?

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* 32. If you answered "no" to the previous question, how interested would you be in joining a disability-focused group, page, or forum?

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25% of survey complete.

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