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Survey of Interest in Peer Visitor Training
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1.
Are you interested in becoming a Certified Peer Visitor for amputees?
(Required.)
Yes
No
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2.
What is your amputation level (e.g. above-knee, below-knee, upper limb, etc.)
(Required.)
above-knee
below-knee
knee disarticulation
hip disarticulation
above-elbow
below-elbow
Other (please specify)
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3.
What is your gender?
(Required.)
Male
Female
Other (please specify)
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4.
What is your age?
(Required.)
Under 21
22-35
36-45
46-55
56-65
Over 65
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5.
How long have you been living with limb loss?
(Required.)
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
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)
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7.
Which is best for you for a training date, weekday or weekend?
(Required.)
weekend
weekday
any day of the week
8.
Do you attend an Amputee Support Group?
Yes
No
Which group(s) do you attend regularly?
9.
If you are interested in becoming a Certified Peer Visitor, please share your contact information.
Name
Phone Number
Email Address