* 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 zip code? (please use the zip code of your home address)

* 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, had difficulty in your own community because of lack of curb cuts, ramps, etc?

* 9. Have you or the person you know with MS had to make modifications to your home to make it more accessible?

* 10. Have you, or the person you know, had difficulty finding and keeping health insurance?

* 11. Have you, or the person with MS that you know, had difficulty paying for MS medications?

* 12. Have you or the person you know with MS had difficulty with health insurance paying for equipment such as wheelchairs, walkers or canes?

* 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?

* 14. Have you or the person you know with MS had difficulty paying for basic needs such as food, rent and utilities?

* 15. If you answered yes to any of the questions above, please take a moment to share your story.

* 16. Please rank these issues with number 1 being the top priority and number 7 being the least.

* 17. Other than the issues mentioned above, are there other issues that you believe we should consider in our advocacy work?

* 18. Do you have any connections with legislators?

* 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.

* 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.

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