Health Information Binder Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The NGCDD would like your feedback on the Health Information Binders! This survey should take less than 3 minutes!

Please check all that apply: *

I am a self-advocate or a person with an I/DD

I am a family member of a self-advocate

I am a professional or other

I live in a rural area of Nevada

I am a male

I am a female

I identify as other than male or female or I choose not to tell you my gender.

Required

What is your race? *

I am Black or African American

I am White

I am Native Hawaiian or other Pacific Islander

I am Asian

I am Native American/American Indian

I am Hispanic or Latino

I am two or more races

I don't know what my race is or I choose not to tell you what my race is.

I feel this binder will help me increase my ability to advocate for myself or other people. *

Yes

I feel this binder will help me be better able to say what I want or need and what is important to me. *

Yes

I am currently able to advocate for myself. *

Yes

I am currently on a disability, policy or advisory board, or serving in a leadership position. *

Yes

I am satisfied with this binder! *

Yes

Do you have any additional comments?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy