Request edit access
Disability Survey of Boston Residents
This survey will help us learn more about people with disabilities who live in Boston. You are not required to fill it out, but it helps the City to improve services for this population. Your answers may be shared, but we will not share your name or specific personal details.
Sign in to Google to save your progress. Learn more
Email *
Instructions: Please fill out a separate survey form for each member of your household who has a disability.
What is your zip code?
How many people live in your household?
Clear selection
Does anyone in your household have a disability?
Clear selection
If the answer above is "yes," how many people in your household have a disability?
Clear selection
Please answer the questions below as they relate to your household member who has a disability (if you are filling this out for another member of your household, use that person's information).
If more than one person in your household has a disability, please fill out separate surveys for each of them.
How old is the person in your household who has the disability?
Clear selection
What is their gender identity?
Clear selection
Please tell us about their race and/or ethnicity (check all that apply).
What is this person's native language?
Clear selection
What other languages can they speak and understand?
Clear selection
Is this person deaf, or do they have serious difficulty hearing?
Clear selection
Is this person blind, or do they have serious difficulty seeing, even when wearing glasses?
Clear selection
Does this person have serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition? (if they are 5 years old or older)
Clear selection
Does this person have serious difficulty walking or climbing stairs? (if they are 5 years old or older)
Clear selection
Does this person have difficulty dressing or bathing themself? (if they are 5 years old or older)
Clear selection
Does this person have difficulty doing errands alone such as visiting a doctor’s office or shopping because of a physical, mental, or emotional condition? (if they are 15 years old or older)
Clear selection
Is this  person employed (if they are 18 years old or older)?
Clear selection
If this person is employed, do they work:
Clear selection
Would you like to add another household member with a disability?
Clear selection
If you answered "yes," please return to the previous page and click on the Disability Survey link again. Thank you!
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of City of Boston. Report Abuse
Google Forms