Interest Form for Healthcare Accessibility Research Project
Thank you for your interest in participating in our research project aimed at improving accessibility in healthcare environments for individuals with visual disabilities. Your insights and experiences are crucial in helping us identify barriers and develop effective solutions for navigating these spaces. Please fill out the form below to share your information and availability.
There are nine questions in this survey.
1. Name:
*
First Name
Last Name
2. E-mail Address:
*
example@example.com
3. Cell Phone Number:
*
123-4456-7890
4.Preferred Method of Contact:
*
Email
Text
Phone Call
Video Chat
5.Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
6.Visual Disability Matrix (Please select all that apply to you):
*
Low Vision
Partially Blind
Legally Blind
Uses White Cane
Uses Guide Dog
Uses Human Guide
Uses Virtual Assistant
Utilizes Public Transportation
Utilizes Private Transportation
7.Availability for participating in healthcare visits and discussions (Please select all that apply):
*
Weekdays (Monday through Friday)
Weekends (Saturday and Sunday)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
8. Times that would work for your schedule (Please select all that apply):
*
Morning (8am - 12pm)
Afternoon (12pm - 4pm)
Evening (4pm - 8pm)
9. Additional Comments:
*
Submit Application
Should be Empty: