Advocacy: This Is My Story (2011) Survey

How do you tell the story of multiple sclerosis?

On our website, in the news, and other places, you'll often see profiles of everyday people who are living with MS or helping move us closer to a world free of this disease.

"This Is My Story" story cards allow persons with MS, family members, friends, and volunteers to share their personal experiences with MS. With your permission, we will create and provide you with a personalized story card that can be distributed to lawmakers to serve as an educational tool to help elected officials learn about and join the movement to create a world free of MS.

If you are willing to share your story for this purpose, use the form below to tell us a little about yourself. The National MS Society will contact you for a follow-up interview and will not use any information without prior consent. Even if you do not wish to have a story card, we appreciate having your story to help support efforts to improve access to health care and defend the rights of people with disabilities.

Thanks!

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1. What is your connection to multiple sclerosis or the National MS Society?

What is your connection to multiple sclerosis or the National MS Society? I have MS

I have a friend with MS

I have a family member with MS

I am a caregiver for someone with MS

I am a healthcare professional

I am a volunteer for the Society

I am a Society event participant or donor

Other

2. Have you ever served in the military?

Have you ever served in the military?

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3. Please tell us about how MS has impacted your life.

Please tell us about how MS has impacted your life.

4. Have you or your loved one experienced any of the following? Check all that apply.

Have you or your loved one experienced any of the following? Check all that apply. Unaffordable health care services due to high costs, lack of insurance coverage, benefit caps, or other reason.

Financial strain due to high prescription drug costs or drug plan tiering.

Unaffordable insurance premiums, trouble accessing coverage, or pre-existing condition exclusion due to MS or other factors.

5. Have you or your loved one experienced any of the following? Check all that apply.

Have you or your loved one experienced any of the following? Check all that apply. Difficulty applying, appealing, or qualifying for Social Security disability benefits.

Waiting 24 months for Medicare after qualifying for Social Security disability benefits..

Trouble obtaining rehabilitation services, preventive care, durable medical equipment, mental health, hospice, or other care.

Difficulty continuing in the workplace or receiving work accommodations.

6. If you selected any of the above, please share that story.

If you selected any of the above, please share that story.

7. Have you or your loved one experienced any of the following? Check all that apply.

Have you or your loved one experienced any of the following? Check all that apply. Difficulty obtaining home- or community-based care.

Trouble accessing housing, home modifications, or transportation options.

Difficulty finding help or relief with caregiving duties.

Challenges with long-term supports.

Challenges related to disability rights or other discrimination related to MS.

8. If you selected any of the above, please share that story.

If you selected any of the above, please share that story.

9. What else should we know about your unique story?

What else should we know about your unique story?

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10. Thank you. We might contact you for more information.

Thank you. We might contact you for more information. Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

Questions? Please contact our Austin office at toll free (877) 524-4044 or (512) 340-2700.

Thank you again!

Advocacy: This Is My Story (2011)
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1. Share Your Story...

Advocacy: This Is My Story (2011)
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