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25
Questions
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1
Name
First Name
Last Name
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2
Age
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3
Phone Number
Area Code
Phone Number
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4
Email Address
example@example.com
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5
Gender
Male
Female
Non Binary
Prefer Not To Say
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6
What type of MS were you diagnosed with?
Relapse Remitting
Secondary Progressive
Primary Progressive
Other Autoimmune Disease
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7
If you chose 'other Autoimmune Disease', what were you diagnosed with?
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8
Are you?
Unemployed
Employed Full Time
Employed Part Time
Self Employed
Contractor
Other
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9
Were you employed when you were diagnosed?
Yes
No
Other
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10
What was the nature of your work
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11
How did the diagnosis effect your job, if at all?
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12
If you gave up your career, can you say a little more about what led to that decision?
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13
Did you seek social welfare assistance?
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14
Do you have an interest in going back to employment?
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15
What would ideal employment look like for you?
Work from home
Work in an office environment
Blend of both
Self Employed
Other
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16
How many hours a week would you like to work?
10 hours or less
20 hours or less
30 hours or less
40 hours or less
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17
Would you require any extra assistance if you chose office environment?
YES
NO
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18
What are your thoughts on telling a potential employer you have MS/another autoimmune disease?
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19
What type of supports do you know of that would help you to go back to work? If any...
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20
If you were to return to employment, what would your concerns be?
Loss of Social Welfare Payment
Stress levels
Potential relapse
Ability to complete the job
Lack of Confidence
Interview
Other
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21
What other concerns might you have?
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22
What are the Pro's of going back to work?
Financial Independence
Confidence
Self Image
Getting out of the House
Self Worth
Inclusion
Increased Activity
Other
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23
How did you learn about MS to Success?
Facebook
TV
Twitter
Instagram
YouTube
Search Engine
Online Ads
Referral
Other
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24
Would you feel comfortable openly speaking to your employer about your diagnosis?
YES
NO
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25
Any additional comments or information you would like to share?
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