Survey

Let’s help each other out by filling out this form so that we can offer you the best solutions and to make the process as accessible as possible. This survey will also be shared with MDH/CCC.

Name(Required)

First Last

Email(Required)

Phone(Required)

Gender(Required)

Age(Required)

Which community do you identify with?(Required)

African American

American Indian

LGBTQ+

Asian American

Deaf, Hard of Hearing, Deafblind

Latinx

Other

What is your ethnic identity?(Required)

African American

Hispanic or Latino American

White

Indigenous/Indian

Asian American

Other

Are you vaccinated against COVID?(Required)

Do you have access to COVID resources or information?(Required)

Do you need support in finding COVID resources or information?(Required)

Do you want us to contact you to provide support?(Required)

Can we add your email to our newsletter?(Required)

Is there anything that you think is important that we should know OR want us to provide in the future related to COVID?

Where do you tend to view your deaf news from?(Required)

Facebook

Youtube

Newsletters

Email blasts

Text blasts

Other

Would you like more information regarding our interpreting and translation services for your personal and/or professional events/appointments?(Required)

Yes

Not Now/Maybe Later

CAPTCHA

Help Us Improve - Take Our Survey!

TAKE THE SURVEY NOW

Subscribe to Our Newsletter

Site Designed and Powered with 🤟🏻 by Eyeth Studios, A Deaf-Owned Company.