Questionnaire on Attitude, Knowledge and Health-seeking Behaviour of Individuals with Special Needs towards COVID-19 (QAKHBISNC)

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Demographic Information

Gender *

Female

Male

Age *

15 - 24

25 - 34

34 - 44

45 and above

Disability Type *

Hearing Impairment

Visual Impairment

Autism

Intellectual Disability

Learning Disabilities

Physical Disabilities

Deaf-blindness

Emotional disorder

Speech and Language Disorder

Other health impairment (OHI) including cancer, sickle-cell anemia, and diabetes

Multiple disabilities

Occupation *

Self-employed

Government Worker

Private Sector Employee

Not Employe

Student

If Student, Name of school/institution

Highest educational qualification *

Primary

Secondary

HND/Degree

NCE/ND

Master Degree

PhD

No Formal Education

Other:

Name of college/university attended

State of Residence *

Living Place *

Apartment

House/Villa

Other:

Family Structure *

Monogamy

Polygamy

Others

Number of people in your household

Less than or equal to 4

Greater than or equal to 5

Clear selection

Locality *

Urban

Semi - Urban

Rural

Marital Status *

Single

Married

Divorced

Widowed

Co-habiting

Seperated

Never Married

Other:

Ethnicity *

State of Residence *

Town of Residence *

Type of assistance technology used (e.g. aids mobility, hearing aids etc.)

Hearing Level (if any)

Mild

Moderate

Severe

Profound

Clear selection

Onset of hearing level loss (If any)

Congenital

Perinatal

Acquired

Clear selection

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