Survey of Interest in Peer Visitor Training Question Title * 1. Are you interested in becoming a Certified Peer Visitor for amputees? Yes No Question Title * 2. What is your amputation level (e.g. above-knee, below-knee, upper limb, etc.) above-knee below-knee knee disarticulation hip disarticulation above-elbow below-elbow Other (please specify) Question Title * 3. What is your gender? Male Female Other (please specify) Question Title * 4. What is your age? Under 21 22-35 36-45 46-55 56-65 Over 65 Question Title * 5. How long have you been living with limb loss? Less than 1 year More than 1 year, less than 2 years More than 2 years, less than 5 years More than 5 years, less than 10 years Over ten years My entire life Question Title * 6. What is the most convenient location for you to attend a training? Enter 5-digit zip code (e.g., home or work) and distance you could travel. Zip Code Distance You Could Travel (e.g., up to 20 miles) Question Title * 7. Which is best for you for a training date, weekday or weekend? weekend weekday any day of the week Question Title * 8. Do you attend an Amputee Support Group? Yes No Which group(s) do you attend regularly? Question Title * 9. If you are interested in becoming a Certified Peer Visitor, please share your contact information. Name Phone Number Email Address SUBMIT