PA Client Advocacy Survey

 
*
1. What is your connection to MS or the National MS Society?
2. Approximately how long have you, or the person you care about, been diagnosed with MS?
*
3. What is your zipcode (please note your home zipcode, not your work)?
4. In which county do you live?
*
5. Have you or the person you know with MS experienced difficulty in finding or affording help/relief from caregiver duties?
*
6. Have you or the person you know with MS experienced difficulty accessing/utilizing transportation/para-transit?
*
7. Have you or the person you know with MS had difficulty in finding affordable/accessible housing?
*
8. Have you or the person you know with MS had to make modifications to your home to make it more accessible?
*
9. Have you, or the person with MS that you know, had difficulty paying for MS medications?
*
10. Have you or the person you know with MS had difficulty with health insurance paying for equipment such as wheelchairs, walkers or canes?
*
11. Have you or the person you know with MS experienced any issues related to employment such as job discrimination or denial of reasonable accommodations?
*
12. Have you or the person you know with MS had difficulty paying for basic needs such as food, rent and utilities?
13. If you answered yes to any of the questions above, please take a moment to share your story.
*
14. Please rate the importance of each of these issues, selecting no more than three issues as a high priority.
HighMediumLow
Caregiver Assistance
Transportation
Accessible/Affordable Housing
Access to Medications
Medical Equipment Issues
Financial Assistance for Basic Necessities
Employment Issues
15. Other than the issues mentioned above, are there other issues that you believe we should consider in our advocacy work?
*
16. Do you have any personal relationships with legislators?
17. If you do have a relationship with a legislator, would you be willing to make an introduction on behalf of hte National MS Society? If so, please list the legislator, and your contact information, in the field below.
18. 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.
Powered by SurveyMonkey
Check out our sample surveys and create your own now!