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Questions About Disabilities
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Name
This field is for validation purposes and should be left unchanged.
Why We’re Asking These Questions:
We want to learn and help you learn more about any disabilities you might have. This will help us support you better, and your answers will be private.
How to Answer:
Please answer the questions as best as you can. If you’re not sure about a question, pick the answer that seems most right for you, or ask for help from an adult you trust.
Do you have any health problems that make it hard to do everyday things?
(Required)
Please choose one.
Yes
No
Not Sure
Do you have trouble with any of these activities? (Check all that apply)
(Required)
Seeing, even with glasses or contact lenses
Hearing, even with a hearing aid
Walking or going up stairs
Remembering things or focusing
Talking, understanding others, reading, or writing
Handling your feelings or mental health
None of the above
Has a doctor, school counselor or specialist ever said you have a disability or condition that affects how you learn or live?
(Required)
Please choose one.
Yes
No
I don’t want to say
Do you use any of these tools or supports to help you every day? (Check all that apply)
(Required)
Wheelchair or something to help you move
Hearing aids or other devices to help you hear
Screen readers, other visual aids, long white cane, or magnification
Extra time or different tests at school
Medicine for mental health or thinking support
Other
None of the above
Do you feel like you need more help or support at school or in daily life?
(Required)
Please choose one.
Yes
No
I don’t want to say
Do you spend part of your day in the special education or resource classroom in school?
(Required)
Please choose one.
Yes
No
I don’t want to say
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