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TAI Testers Survey
For all TAG (Tech Access Group) members to complete
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.
*
1.
Are you a member of United Spinal? Membership is free.
(Required.)
Yes
No.
Click here to join.
2.
What is your United Spinal chapter affiliation: (if applicable)
If you would like to join a chapter network
click here
.
*
3.
Please provide your contact information:
(Required.)
Name
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP Code
Email preference
*
4.
In what year were you born? (enter 4-digit birth year; for example, 1976) Testers must be 18 years of ago or older.
(Required.)
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
*
6.
Are you of Spanish, Hispanic or Latino origin or descent?
(Required.)
No, not Spanish/Hispanic/Latino
Yes, Hispanic
Yes, Latino
Prefer not to answer
*
7.
What is your gender?
(Required.)
Female
Male
Transgender
Non-binary/third gender
Do not identify as male, female, non-binary or transgender
Prefer not to answer
8.
Please provide your social media (personal or professional). This will not be shared without your permission.
Facebook
Instagram
Twitter
LinkedIn
9.
Please provide other disability organization affiliations and your role (List any or all)
*
10.
Please select the disability that has impacted your mobility:
(Required.)
Spinal cord injury
Multiple Sclerosis
Amyotrophic Lateral Sclerosis
Cauda Equina
Cerebral Palsy
Fibromyalgia
Guillain-Barre Syndrome
Lupus
Other
Parkinson's Disease
Spina Bifida
Spinal Muscular Atrophy
Spinal Stenosis
Stroke
Tethered Spinal Cord Syndrome
Transverse Myelitis
Traumatic Brain Injury
Tethered Spinal Cord
None
*
11.
Which of the following best describes your functional level?
(Required.)
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)
12.
For those with SCI, please indicate your neurological level:
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
14.
Would you like to disclose any other disabilities or identities that add to your perspective intersectionality? If so, please provide:
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
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)
*
17.
For your personal vehicle, are you the primary driver?
(Required.)
Yes
No
N/A
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
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)
*
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.
(Required.)
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
Interest
Expertise
Mobility tech devices
Interest
Expertise
Artificial Intelligence
Interest
Expertise
Autonomous vehicle
Interest
Expertise
Video game accessibility
Interest
Expertise
Smart home devices
Interest
Expertise
Tech related policies
Interest
Expertise
Other (please specify)
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):
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):
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No file chosen
United Spinal privacy policy
Current Progress,
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