MDA Transitions Survey

1. Check the items that best describe you.

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* 1. My age:

Under 17

18-21

22-25

26-30

31-35

35-40

Over 40

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* 2. My gender:

Male

Female

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* 3. I was diagnosed with a neuromuscular disease:

Before age 10.

Between ages 10 and 18.

After age 18.

I do not yet have a confirmed diagnosis of a neuromuscular disease.

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* 4. My mobility: (check all that apply)

I use a power wheelchair or power scooter full time.

I use a power wheelchair or power scooter part time.

I use a manual wheelchair full time.

I use a manual wheelchair part time.

I am able to perform my own transfers.

I use an assistive walking aid (leg braces, walker, cane, crutch, etc).

I am able to walk without assistance.

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* 5. My primary residence: (check all that apply)

I live with my parents.

I live with a family member other than my parents (adult sibling, cousin, etc.).

I live on my college campus.

I live in my own rented apartment or house.

I own my own home.

I live with my spouse/partner.

I live in a group residential setting.

I live in a medical facility or assisted living facility.

I do not have a permanent residence.

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* 6. My primary sources of daily physical care assistance: (Check all that apply)

I can independently perform all of my activities of daily living.

My parents, spouse, or other unpaid family members help with my physical care.

I employ one or more personal care attendants.

Other (please specify)

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* 7. If you employ paid care attendants, which of the following best describes your funding sources: (check all that apply)

Self-pay

Private health insurance

Medicaid waiver

Medicaid

Medicare

State funding program

Federal funding program

Vocational rehabilitation program

Other

Other (please specify)

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* 8. My academic status: (check all that apply)

I am currently in high school.

I did not complete high school.

I am a high school graduate.

I have a GED.

I am currently in college.

I have some college courses but did not graduate.

I am a college graduate.

I am in graduate/professional school.

I have a graduate/professional degree.

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* 9. My employment status: (check all that apply)

I am a student and not currently employed.

I am employed full time in my preferred field.

I am employed full time, but not in my preferred field.

I am employed part time in my preferred field.

I am employed part time, but not in my preferred field.

I have an unpaid internship.

I volunteer 20 hours or more per week.

I would like to be employed but am unable to find employment.

I have not sought employment for fear that the income I earn would make me ineligible for critical disability benefits and/or assistance.

I am not employed and am not currently looking for a job.

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* 10. Physical accommodations to my school and assistive techniology have been provided by -- check all that apply (please complete based on current and past school experience):

My school.

Vocational rehabilitation services.

A state or federally funded technology assistance program other than vocational rehabilitation services or my school.

No one. I have needed school accommodations or assistive technology but have not been able to get funding for them.

I did not/do not require any accommodations while in school.

Other (please specify)

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* 11. Please describe the types of accommodations or assistive technologies that you have found useful at school (if applicable, e.g., note-takers, height-adjustable tables, voice recognition software, elevator pass, change in class location):

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* 12. My workplace accommodations: (check all that apply)

Physical accommodations to my workspace and assistive technology have been provided by my employers.

Physical accommodations to my workspace and assistive technology have been provided by vocational rehabilitation services.

Physical accommodations to my workspace and assistive technology have been provided by a state and federally funded technology assistance program other than vocational rehabilitation services.

I have a service animal that comes to work with me.

I have been unable to have needed physicial workplace accommodations or assistive technology funded in my current job.

I have been unable to have needed physical workplace accommodations or assistive technology funded in my past employment.

I have no current physical accommodation or technology assistance needs.

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* 1. My age:

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* 2. My gender:

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* 3. I was diagnosed with a neuromuscular disease:

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* 4. My mobility: (check all that apply)

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* 5. My primary residence: (check all that apply)

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* 6. My primary sources of daily physical care assistance: (Check all that apply)

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* 7. If you employ paid care attendants, which of the following best describes your funding sources: (check all that apply)

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* 8. My academic status: (check all that apply)

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* 9. My employment status: (check all that apply)

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* 10. Physical accommodations to my school and assistive techniology have been provided by -- check all that apply (please complete based on current and past school experience):

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* 11. Please describe the types of accommodations or assistive technologies that you have found useful at school (if applicable, e.g., note-takers, height-adjustable tables, voice recognition software, elevator pass, change in class location):

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* 12. My workplace accommodations: (check all that apply)

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* 13. Please describe the types of accommodations or assistive technologies that you have found useful in your workplace (if applicable):