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2021 New Mobility Survey
11.
Tell Us About Yourself
The purpose of this survey is to improve New Mobility's content. Your personal information will not be shared outside of our organization. Estimated time to complete the survey: 15 minutes. Thank you for your input!
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1.
Please indicate your age range:
(Required.)
Under 18
18 - 25
26 - 35
36 - 45
46 - 55
56 - 65
Over 65
2.
Please indicate your gender:
Female
Male
Non-binary
Prefer not to answer
Not listed (optional to specify)
3.
How would you describe yourself?
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Other (optional to specify)
4.
What is your annual household income? (Include all family members)
Less than $20,000
$20,000 - $30,000
$30,000 - $50,000
$50,000 - $75,000
$75,000 - $100,000
$100,000 - $200,000
More than $200,000
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5.
What is your highest level of education?
(Required.)
Some high school
High school diploma or GED
Trade school
Some college
Associate's degree
Bachelor's degree
Master's degree
Doctorate
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6.
What is your employment status?
(Required.)
Full time
Part time
Unemployed, looking for work
Unemployed, not looking for work
Retired
Student
Homemaker
Self-employed
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7.
What employment barriers cause you difficulty? (Choose up to 3)
(Required.)
Transportation to work
Access issues
Paying for my caregiving
Discrimination at work
Lack of accommodation
Inadequate health insurance
Teleworking issues
None
Not currently working
Other or Details on above issues
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8.
Which of the following best describes you?
(Required.)
Person with a disability
PCA/caregiver
Family member of a person with a disability
Professional working with people with disabilities (please specify OT, PT, rec therapist, nurse, physician, case manager, DME provider, researcher, etc.)
None of the above
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9.
Which of the following do you use? (check all that apply)
(Required.)
Manual wheelchair
Power wheelchair
Power assist device (SmartDrive, Smoov One, E-motion, etc.)
Scooter
Walker/rollator
Crutches
Cane
Braces
None of the above
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10.
How many years since the onset of your disability?
(Required.)
Born with disability
Less than 1 year
1 - 3 years
3 - 5 years
5 - 10 years
10 - 20 years
20 - 30 years
30 - 40 years
More than 40 years
Not disabled
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11.
Please indicate the nature of your disability: (check all that apply)
(Required.)
Spinal cord injury
Amputee
Chronic pain
Cerebral palsy
ALS
Brain injury
Incontinence
Multiple sclerosis
Muscular dystrophy
Nerve/muscle disorder
Osteogenesis imperfecta
Post-polio
Scoliosis
Spina bifida
Stroke
Parkinson's
Not disabled
Other (please specify)
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12.
Are you a member of any disability organizations?
(Required.)
No
Yes
(Please list up to three organizations you are a member of)
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13.
Are you a veteran?
(Required.)
Yes
No
14.
Do you have a service animal?
No
Yes (please specify type of animal)
15.
New Mobility celebrates diversity and wants to understand the complexity of our readers' lives. Please use this space to include anything we didn't ask about but that you'd like us to know about your background.
