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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
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Last
Email
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Phone
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Gender
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Male
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Agender
My gender isn't listed
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Age
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Under 18
18-24
25-34
35-44
45-54
55-64
65 or Above
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Which community do you identify with?
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African American
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Asian American
Deaf, Hard of Hearing, Deafblind
Latinx
Other
What is your ethnic identity?
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African American
Hispanic or Latino American
White
Indigenous/Indian
Asian American
Other
Are you vaccinated against COVID?
(Required)
Yes
No
Not sure
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Do you have access to COVID resources or information?
(Required)
Yes
Somewhat
No
Not sure
Rather not say
Do you need support in finding COVID resources or information?
(Required)
Yes
Somewhat
No
Not sure
Rather not say
Do you want us to contact you to provide support?
(Required)
Yes - by phone
Yes - by email
No
Can we add your email to our newsletter?
(Required)
Yes
No
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?
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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
No
Not Now/Maybe Later
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