APHA Disability Justice as a Health Equity Imperative Advisory Board Survey

1.Name(Required.)

2.Email(Required.)

3.What best describes your place of work?(Required.)

Other (please specify)

4.Job title (if applicable)(Required.)

5.City and state you are located in(Required.)

6.To make sure that this is a good fit, we want to make sure that advisory board members have the time to fully engage. We think that these activities will require roughly 3-5 hours a month on average over the next year. If that sounds feasible with your schedule please select all that apply(Required.)

I can commit to meeting virtually for four 60-90 minute meetings

I can commit to regularly checking in with the other members of the board and APHA staff

I can commit to providing your feedback to guide key project activities throughout your time on the board during and between meetings

I do not have the capacity to engage at this time

Other (please specify)

7.In order to ensure a diverse and inclusive board, please share any lived experience or identity you are comfortable sharing. We particularly want to know how Disability and ableism have impacted your life. If you are not comfortable sharing, no worries!

8.What type(s) of disabilities do you have? (Check all that apply)

Chronic Health Illness/Disability (A person living with a condition such as asthma, diabetes, cardiovascular/heart disease, HIV, TB, POTS, EDS, etc.)

Learning Disability (A person living with a disability that may or may not impact their ability to learn, read, write, think, etc. such as dyslexia, dysgraphia, dyscalculia, a specific learning disability, etc.)

Mental Health or Intellectual/Developmental Disability (A person who has anxiety, attention deficit or hyperactivity disorder (ADD or ADHD), Autism spectrum, depression, post-traumatic stress disorder (PTSD), racial trauma or race-based traumatic stress (RBTS), or another mental health disability (e.g. schizophrenia, an eating disorder, etc.) developmental disability (e.g. cerebral palsy, down syndrome)

Physical Disability (A person who has a mobility condition that may or may not affect walking, a speech or communication disorder, a traumatic or acquired brain injury (TBI), etc.)

Sensory Disability (A person who is blind or has low vision, deaf or hard of hearing, etc.)

Prefer not to disclose

I do not currently have a Disability

Other (please specify)

9.What is your personal/professional experience working with people with Disabilities and their families/caregivers/advocates/allies?(Required.)

10.What is your experience working with BIPOC individuals with Disabilities and centering intersectionality?(Required.)

11.Why do you want to serve on the advisory board? Please share your motivations for serving on the advisory board and any relevant skills or experience you would bring to this advisory board?(Required.)

12.Are you an APHA member?(Required.)

Yes

No

13.Have you ever served on an advisory board or group with APHA before?

Yes

No

Other (please specify)

14.How can we make sure that the advisory board activities including meetings are accessible to you? What accommodations do you need?

What APHA is committed to providing: captioning meetings with zoom automatic captions, agendas in advance of meetings, notes after meetings, multiple methods of engagement, communicating in plain language. The APHA team will make a plan with any members needing additional accommodations in order to ensure their needs are met.(Required.)

15.Please select your gender identity (Select all that apply)(Required.)

Woman

Man

Transgender Man/Trans Man/Female-to-Male

Transgender Woman/Trans Woman/Male-to-Female

Genderqueer (neither exclusively male nor female)/Gender non-conforming/Non-binary

Other gender category

Prefer not to say

Other (please specify)

16.Do you identify as a part of the LGBTQIA2S+ community?

Yes

No

17.What is your race or ethnicity? (Select all that apply)(Required.)

Other (please specify)

19.Comment and/or questions