* 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.

  High Medium Low
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.

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