TSF GRANT APPLICATION (Track 2) Intro Question Title * 1. What is your first name? Question Title * 2. What is your last name? Question Title * 3. What is your street address? Question Title * 4. In what city do you currently live in? Question Title * 5. In what state do you currently live in? Question Title * 6. Zip Code Question Title * 7. What is your preferred method of contact? Question Title * 8. Phone Number Question Title * 9. Email Question Title * 10. Date of birth. Month/Date/Year Date Question Title * 11. Which of the following options most closely aligns with your gender? Female Male Transgender Non-binary/third gender Do not identify as male, female, non-binary or transgender Prefer not to answer Question Title * 12. What is your ethnicity? (Please select all that apply.) Asian Black or African American Hispanic or Latino Middle Eastern or North African Multiracial or Multi ethnic Native American or Alaska Native Native Hawaiian or other Pacific Islander White/Caucasian None of the above Prefer not to answer Other (please specify) Question Title * 13. What language(s) do you speak at home? Question Title * 14. Marital Status Single Married Living Together Separated Divorced Widowed Question Title * 15. Are you a United States Veteran? Yes No Question Title * 16. What type of disability do you have? Spinal Cord Injury (SCI) Guillain-Barre Syndome Transverse Myelitis Traumatic Brain Injury (TBI) Non-Traumatic Brain Injury Stroke Cerebral Palsy Other: Other (please specify) Question Title * 17. Would you like to disclose any other disabilities or identities that add to your intersectionality? If yes, please specify below. Question Title * 18. In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor Question Title * 19. Do you have limited or no arm function? Yes No Question Title * 20. Do you have limited or no hand function? Yes No Question Title * 21. Do you have limited or no finger function? Yes No Question Title * 22. If selected, will you be able to attend a video meeting? to discuss what technology you need? Yes No Question Title * 23. Do you know what assistive technology would best fit your needs? Yes No Question Title * 24. If your answer to Question 23 was yes, please list device(s) below. Question Title * 25. If needed, do you have assistance with installing the assistive device(s)? Yes No Depends on the device received Question Title * 26. Have you received assistance from the TSF Foundation in the past? Yes No Question Title * 27. Have you applied for assistance from other organizations for the technology you are requesting? Yes No Question Title * 28. If yes, list organization(s) below. Question Title * 29. How will receiving this technology improve your independence and/or quality of life? (2-5 sentences) Question Title * 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? Extremely interested Very interested Somewhat interested Not so interested Not at all interested Question Title * 31. Are you a part of any disability-focused support groups, Facebook groups or online forums? Yes No Question Title * 32. If you answered "no" to the previous question, how interested would you be in joining a disability-focused group, page, or forum? Extremely interested Very interested Somewhat interested Not so interested Not at all interested Next
