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disability.md

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Dis/Ability

Do you identify as a person with a disability? For the purpose of this survey we define disability as a long-term physical, mental, intellectual or sensory impairment which, in interaction with various attitudinal and environmental barriers, hinders your full and effective participation in society on an equal basis with others.

  • Yes
  • No

If you answered yes, what parts of your life does your disability affect?

  • My disability affects focus, memory, and attention.
  • My disability affects my emotions and how I perceive the emotions of others.
  • My disability affects my hearing.
  • My disability affects my mood, thinking, and behavior.
  • My disability affects how I move.
  • My disability affects my vision.
  • My disability affects another part of my life as follows: __________________.
  • I do not have a disability.
  • Prefer not to answer.

Does your disability affect how you work?

  • Yes
  • No
  • I do not have a disability.
  • Prefer not to answer.