NJ Client Advocacy Survey Question Title * 1. What is your connection to MS 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 volunteer for the Society Other Question Title * 2. Approximately how long have you, or the person you care about, been diagnosed with MS? Less than 1 year 1-5 years 6-10 years 11-15 years 16+ years Not sure Other (please specify) Question Title * 3. What is your zip code? (please use the zip code of your home address) Question Title * 4. In which county do you live? Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren Question Title * 5. Have you or the person you know with MS experienced difficulty in finding or affording help/relief from caregiver duties? Yes No Question Title * 6. Have you or the person you know with MS experienced difficulty accessing/utilizing transportation/para-transit? Yes No Question Title * 7. Have you or the person you know with MS had difficulty in finding affordable/accessible housing? Yes No Question Title * 8. Have you, or the person you know, had difficulty in your own community because of lack of curb cuts, ramps, etc? Yes No Question Title * 9. Have you or the person you know with MS had to make modifications to your home to make it more accessible? Yes No Question Title * 10. Have you, or the person you know, had difficulty finding and keeping health insurance? Yes No Question Title * 11. Have you, or the person with MS that you know, had difficulty paying for MS medications? Yes No Question Title * 12. Have you or the person you know with MS had difficulty with health insurance paying for equipment such as wheelchairs, walkers or canes? Yes No Question Title * 13. Have you or the person you know with MS experienced any issues related to employment such as job discrimination or denial of reasonable accommodations? Yes No Question Title * 14. Have you or the person you know with MS had difficulty paying for basic needs such as food, rent and utilities? Yes No Question Title * 15. If you answered yes to any of the questions above, please take a moment to share your story. Question Title * 16. Please rank these issues with number 1 being the top priority and number 7 being the least. 1 2 3 4 5 6 7 Caregiver Assistance 1 2 3 4 5 6 7 Transportation 1 2 3 4 5 6 7 Accessible/Affordable Housing 1 2 3 4 5 6 7 Access to Medications 1 2 3 4 5 6 7 Medical Equipment Issues 1 2 3 4 5 6 7 Financial Assistance for Basic Necessities 1 2 3 4 5 6 7 Employment Issues Question Title * 17. Other than the issues mentioned above, are there other issues that you believe we should consider in our advocacy work? Question Title * 18. Do you have any connections with legislators? Yes No Question Title * 19. If you do have a relationship with a legislator, would you be willing to make an introduction on behalf of the National MS Society? If so, please list the legislator, and your contact information, in the field below. Question Title * 20. Would you like more information about how to get involved in our advocacy efforts? If so, please fill give us your name and contact information. Done