Equal Access in Science and Medicine Survey
Your survey data will be used to inform new disability-related programming at the East Baltimore campus. Data from multiple choice questions will be shared only in aggregate. Personally identifiable information from free response questions will be redacted before survey data are shared. You may skip any questions that you do not feel comfortable answering.
Sign in to Google to save your progress. Learn more
What is your division?
Clear selection
What is your degree program? (e.g., MSN, NP, MSPH, PhD, MD, postdoctoral fellow)
Do you have a physical or mental impairment that substantially limits one or more major life activities?
Impairments can include any physiological, mental, and/or psychological disorder. Examples of major life activities include caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, interacting with others, and working.
Clear selection
Do you have a:
If you have any of the conditions listed in the previous question, what specific condition(s) do you have? (e.g., anxiety disorder, ADHD, vision loss, fibromyalgia)
On a scale of 1 to 5, how much of a problem is each of the following to you?
1 None
2
3
4
5 Extreme
Not applicable
Should you need help, how much of a problem is getting help from a close family member (including your partner)?
Should you need help, how much of a problem is getting help from friends and co-workers?
How much of a problem is looking after your health, eating well, exercising, or taking your medicines?
How much of a problem is accessing and paying for appropriate medical care?
How much of a problem is feeling tired and not having enough energy?
How much of a problem is coping with all the things you have to do?
How much of a problem do you have with getting your household tasks done?
How much of a problem do you have with joining community activities, such as festivities, religious events, or other activities?
How much of a problem do you have with socializing and engaging with friends and family?
How much of a problem is using public or private transportation?
How much of a problem is getting things done as required at work or school?
Clear selection
Do you identify as disabled and/or having a disability?
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy