Interest Form for Healthcare Accessibility Research Project

Interest Form for Healthcare Accessibility Research Project
Thank you for your interest in participating in disABILITYsa's (disability s a) research project aimed at improving accessibility in healthcare environments for individuals with visual disabilities in partnership with UTSA.

People who are blind or have low vision face unique challenges navigating healthcare facilities, especially when clear wayfinding and accessible design are lacking. Your insights and experiences are crucial in helping us identify barriers and develop effective solutions for navigating these spaces.

Participants will join our research team to visit local healthcare facilities, share personal navigation experiences, help identify what works and what needs improvement, and then take part in focus groups over the next couple of months.
Please fill out the form below to share your information and availability. There are eight required and one optional question in this form.
1. Name:*

First NameLast Name
2. E-mail Address:*
example@example.com
3. Cell Phone Number:*
123-4456-7890Format: (000) 000-0000.
4. Preferred Method of Contact:*

EmailSMS TextPhone Call
5. Residential Address:*

Street Address

Street Address Line 2

CityState

Zip Code
6. Visual Disability Matrix (Please select all that apply to you):*

Low VisionPartially BlindLegally BlindUses White CaneUses Guide DogUses Human GuideUses Virtual AssistantUtilizes Public TransportationUtilizes Private Transportation
7. Typical availability for participating in healthcare visits and focus groups (Please select all that apply):*

Weekdays (Monday through Friday)Weekends (Saturday and Sunday)MondayTuesdayWednesdayThursdayFridaySaturdaySunday
8. Times that would typically work for your schedule (Please select all that apply):*

Morning (8 am - 12 pm)Afternoon (12 pm - 4 pm)Evening (4 pm - 8 pm)
9. I am available for the next opportunity on Friday, October 17th from 9am to 4pm.*

YesNo
10. Additional Comments:
Should be Empty: