TAI Testers Survey

This information that you provide will be used to best match you with the opportunities Tech Access has for Research and Development and User Experience.

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* 1. Are you a member of United Spinal? Membership is free.

Yes

No. Click here to join.

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* 2. What is your United Spinal chapter affiliation: (if applicable)

If you would like to join a chapter network click here.

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* 3. Please provide your contact information:

Name

City/Town

State/Province

ZIP Code

Email preference

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* 4. In what year were you born? (enter 4-digit birth year; for example, 1976) Testers must be 18 years of ago or older.

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* 5. What is your race or ethnicity?

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Multiracial or Multiethnic

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

None of the above

Prefer not to answer

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* 6. Are you of Spanish, Hispanic or Latino origin or descent?

No, not Spanish/Hispanic/Latino

Yes, Hispanic

Yes, Latino

Prefer not to answer

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* 7. What is your gender?

Female

Male

Transgender

Non-binary/third gender

Do not identify as male, female, non-binary or transgender

Prefer not to answer

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* 8. Please provide your social media (personal or professional). This will not be shared without your permission.

Facebook

Instagram

Twitter

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* 9. Please provide other disability organization affiliations and your role (List any or all)

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* 10. Please select the disability that has impacted your mobility:

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* 11. Which of the following best describes your functional level?

Paraplegia with some leg function

Paraplegia without leg function

Hemiplegia

Quadriplegia without finger function

Quadriplegia with some arm function

Quadriplegia without arm function

Other function level (please provide a brief description)

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* 12. For those with SCI, please indicate your neurological level:

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* 13. What is your level of injury?

Cervical 1-4 (upper neck)

Cervical 5-8 (lower neck)

Thoracic 1-6

Thoracic 7-12 (mid back)

Lumbar 1-5 (lower back)

Sacral 1-5 (tail bone area/cauda equina/conus medullaris)

Not sure/unknown

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* 14. Would you like to disclose any other disabilities or identities that add to your perspective intersectionality? If so, please provide:

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* 15. Please provide the make and model of wheelchair(s) and mobility devices you own: (leave blank any that do not apply to you)

Manual chair

Power chair

Mobility scooter

Standing wheelchair

Sports wheelchair

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* 16. What type of transportation do you use most frequently? (select only one)

Paratransit services

Ridesharing (Uber/Lyft etc.)

Subway/train

Personal vehicle (please specify make and model)

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* 17. For your personal vehicle, are you the primary driver?

Yes

N/A

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* 18. Please elaborate specifics on your use of the following products (use N/A for items or services you do not own):

Smart phone make and model

Laptop computer model

Desktop computer model

Smart speaker(s) (Amazon Alexa, Google Nest, Apple Homepod, etc.)

Environmental controls

Virtual Reality

Cable Service

Internet service

Gaming controllers

Other

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* 19. Please select the assistive technology device(s) that you utilize: (check all that apply)

Eye tracker

Speech to text software

Screen Reader

Mouth mouse

Proportional head control mouse

Switch control

Mouth sticks

Typing aides

Joystick controller

Adaptive video game controller

Internet connected mobility or healthcare device(s)

I do not require assistive technology

Other assistive technology device usage (please specify)

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* 20. Please tell us a bit more about yourself and your relationship with technology, including any specific training or professional technology related experience or perspective. Prior training is not a requirement to sign up.

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* 21. Beyond personal computing and their related assisted technology devices, please list any other tech areas you are specifically interested in or have expertise with:

	Interest	Expertise
Medical device tech	Medical device tech Interest	Medical device tech Expertise
Mobility tech devices	Mobility tech devices Interest	Mobility tech devices Expertise
Artificial Intelligence	Artificial Intelligence Interest	Artificial Intelligence Expertise
Autonomous vehicle	Autonomous vehicle Interest	Autonomous vehicle Expertise
Video game accessibility	Video game accessibility Interest	Video game accessibility Expertise
Smart home devices	Smart home devices Interest	Smart home devices Expertise
Tech related policies	Tech related policies Interest	Tech related policies Expertise

Other (please specify)

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* 22. United Spinal’s Tech Access program has opportunities for members in the following areas. Please select the activities in which you would like to participate. Please mark as many boxes as possible that apply to you (compensation for time and expense will vary):

Product research and design testing

Product testing and review video demonstration or video blog

Tech subject related blogging or article writing

Focus group participation – virtual

Focus group participation – in person

Notifications of related clinical trials

Tech usage survey design

Tech usage survey participation

United Spinal representation at tech events local to your area

United Spinal representation at tech events that require travel beyond your local area

Disability awareness for tech organizations

Adaptive technology training facilitator

Other ways you would like to contribute (please specify):

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* 23. For those interested in public speaking opportunities, please upload a personal bio (150-200 words) highlighting your background and any tech or advocacy-related skills or previous experience (if available include any links to presentations or conferences that you have been a part of):

TAI Testers Survey

For all TAG (Tech Access Group) members to complete

Question Title

* 1. Are you a member of United Spinal? Membership is free.

Question Title

* 2. What is your United Spinal chapter affiliation: (if applicable)

Question Title

* 3. Please provide your contact information:

Question Title

* 4. In what year were you born? (enter 4-digit birth year; for example, 1976) Testers must be 18 years of ago or older.

Question Title

* 5. What is your race or ethnicity?

Question Title

* 6. Are you of Spanish, Hispanic or Latino origin or descent?

Question Title

* 7. What is your gender?

Question Title

* 8. Please provide your social media (personal or professional). This will not be shared without your permission.

Question Title

* 9. Please provide other disability organization affiliations and your role (List any or all)

Question Title

* 10. Please select the disability that has impacted your mobility:

Question Title

* 11. Which of the following best describes your functional level?

Question Title

* 12. For those with SCI, please indicate your neurological level:

Question Title

* 13. What is your level of injury?

Question Title

* 14. Would you like to disclose any other disabilities or identities that add to your perspective intersectionality? If so, please provide:

Question Title

* 15. Please provide the make and model of wheelchair(s) and mobility devices you own: (leave blank any that do not apply to you)

Question Title

* 16. What type of transportation do you use most frequently? (select only one)

Question Title

* 17. For your personal vehicle, are you the primary driver?

Question Title

* 18. Please elaborate specifics on your use of the following products (use N/A for items or services you do not own):

Question Title

* 19. Please select the assistive technology device(s) that you utilize: (check all that apply)

Question Title

* 20. Please tell us a bit more about yourself and your relationship with technology, including any specific training or professional technology related experience or perspective. Prior training is not a requirement to sign up.

Question Title

* 21. Beyond personal computing and their related assisted technology devices, please list any other tech areas you are specifically interested in or have expertise with:

Question Title

* 22. United Spinal’s Tech Access program has opportunities for members in the following areas. Please select the activities in which you would like to participate. Please mark as many boxes as possible that apply to you (compensation for time and expense will vary):

Question Title

* 23. For those interested in public speaking opportunities, please upload a personal bio (150-200 words) highlighting your background and any tech or advocacy-related skills or previous experience (if available include any links to presentations or conferences that you have been a part of):