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1. Name and Contact details
The questions with an asterisk * are mandatory
First name:
*
Last name:
Phone Numbers
International phone number code
UK +44
USA +1
Australia +61
Ireland +353
Canada +1
NewZealand +64
Other
Preferred contact method:
*
Please contact me via email
I would like to be contacted in another way
Other preferred contact methods:
SMS / Text message
Phone call
Video call - WhatsApp or other
Voice message - WhatsApp or other
Text relay service
Other, please provide details
"Other, please provide details"
2. Your online community login details
Your user name for the online Open Inclusion community:
*
3. About you
Country you live in:
*
Please select from list
UK
USA
Australia
Ireland
Canada
New Zealand
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Democratic Republic)
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, (Burma)
Namibia
Nauru
Nepal
Netherlands
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Region or state:
*
Please select from list
London
South East
South West
East England
East Midlands
West Midlands
Yorkshire and The Humber
North East
North West
Scotland
Wales
Northern Ireland
British Isles
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Leinster
Ulster
Munster
Connacht
Alberta
British Columbia
Manitoba
New Brunswick
New found land And Labrador
North West Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Auckland
New Plymouth
Wellington
Nelson
Canterbury
Otago
Not Applicable
Year were you born:
*
Gender:
*
Female
Male
Non-binary
Transgender man
Transgender woman
Transgender non-binary
Would prefer not to say
Let me type my own answer
"Let me type my own answer"
4. Accessibility needs and assistive technology
Sensory needs:
D/deaf
Hard of hearing or hearing impaired
Tinnitus
Blind
Partially sighted / low vision
Colour perception deficiency / colour blind
Limited or no smell or taste
Other sensory access needs
"Other sensory access needs"
Physical needs:
Cannot Walk
Cannot walk far or without difficulty
Balance challenges
Short of stature
Lower limb difference
Limited mobility (restricted movement, paralysis, muscular control etc.)
Hand or upper limb difference
Other limited dexterity (tremor, low grip strength, arthritis, or control etc.)
Clinically obese
Other physical access needs
"Other physical access needs"
Cognitive and mental health needs:
Memory challenges (ongoing or fluctuating, dementia, brain fog etc.)
Focus challenges (ADD/ADHD)
Specific learning difficulty (Dyslexia, Dyspraxia or Dyscalculia)
Generalised learning disabilities
Social and/or sensory challenges (e.g. autism spectrum)
Heightened anxiety
Depression
Post-traumatic stress disorder
Eating disorders
Substance abuse or other addictions
Other mental health conditions (OCD, bipolar, personality disorders etc.)
Communication needs:
Nonverbal
Occasionally nonverbal
Speech impairment (stutter, articulation etc.)
Difficulty with word recall (aphasia)
Other communication challenges
"Other communication challenges"
Chronic health needs:
Chronic pain
Heart or lung conditions
Post stroke
Cancer (current treatment / post treatment)
Auto-immune disease (MS, Celiac, Arthritis, Crohns, diabetes etc.)
Other long-term condition (epilepsy, ME etc.)
Other
None of the above
Prefer not to say
Other (please specify)
"Other (please specify)"
If you have more than one access need, what would you say is your primary need/needs?
*
At what age did you incur your primary need ?
*
Please select age bracket
0-7
8-14
15-25
26-40
41-60
61-70
71-80
81+
Temporary access needs:
Digital and screen technologies, including hardware:
Screen reader software (VoiceOver, TalkBack, JAWS, NVDA etc.)
Screen magnification (e.g. ZoomText)
Resizing / enlargement of text
High contrast mode, dark mode, or other colour changes
Refreshable Braille device
Audio description
Speech recognition software (Dragon, Braina, Voice Finger etc.)
Mainstream voice assistants (Siri, Alexa, Cortana, Google Assistant)
Read aloud software (text to speech such as Read&Write, Natural Reader, Speechify, TextHelp)
Closed captions / subtitles for audio content
Telecommunications device for the deaf (TDD) or teletypewriter (TTY)
Alternative keyboard
Alternative mouse or stylus
Alternative touch screen interaction (doesn't use forefinger / thumb)
Switch navigation
Joystick or trackball
Head pointers, mouth stick or eye tracking
Noise cancellation headphones used for sensory sound control
Magnifying glass
Movement, canes and service animals:
Power wheelchair user
Manual wheelchair user
Mobility scooter user
Adapted private vehicle
Prosthetic/s (upper limb)
Prosthetic/s (lower limb)
Walking aids – stability cane, crutcher/s, frame
Service animal (guide dog for navigational support)
Service animal (other)
Navigational, guide or symbol mobility cane
Other navigational or mobility aid
Communication, verbal and written preferences:
Sign language user
Lip reader
Cochlear Implant / Bionic ear
Hearing aid/s
Augmented assistive communication (manual or digital AAC)
Printed material preferred in Braille
Printed material preferred in large text / high contrast
Easy read content preferred
Personal support and home:
I have a full time professional carer
I have a part time/ occasional professional carer
I have a unpaid carer support (family or other)
I am a carer
Smart home adaptations
Hoist
Adapted spaces (bathroom, kitchen, access etc.)
Adapted products (kitchen tools, clothing/dressing etc.)
Other
None of the above
Prefer not to say
Other (please specify)
"Other (please specify)"