Introduction Survey

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Introduction Survey

For questions or assistance filling out this survey, please contact - deaffriendlyroc@CityofRochester.Gov

The information collected below will be used to aid this project with: appropriate diverse representation, requesting accessibility accommodations, addressing participants appropriately, etc. and will not be shared with anyone not involved in this project.

Equal Employment Opportunity Statement:

The City of Rochester is committed to creating and supporting a workplace and services that are free from discrimination and harassment, promote fairness and equity and value the contributions of all its employees and citizens. We believe that people of diverse backgrounds and beliefs enrich our City and our work environment and we are committed to promoting the dignity of, and interacting positively with, all.

The City of Rochester's Diversity and Inclusion philosophy is embedded in our values & Guiding Principles: We will treat everyone with respect, courtesy, and dignity, and will interact in a way that appreciates the diversity and uniqueness of all.

The City of Rochester remains committed to a policy of equal employment opportunity for all City employees and applicants for City employment, as established by both Federal and State law. We reaffirm our legal obligation and organizational commitment to foster an employment environment free from discrimination and to consider all employees for placement, development programs, job assignments, transfers and promotions regardless of age, race, color, creed, sex, religion, national origin, sexual orientation, gender identity or expression, genetic information, physical or mental disability, marital status, military status/service, or domestic violence victim status.

Full Name: *

Email Address *

Video Phone Number - if you do not wish to share it please type N/A *

Text number - if you do not wish to share it please type N/A *

Preferred name & Pronouns - if you do not wish to share please type N/A *

Age Range: *

18-24

25-34

35-54

55-64

65 and older

Gender Identity *

Male

Non-binary

Prefer not to say

Female

Prefer to self describe below

Gender Identity self description:

Race/Ethnicity: *

African American

Asian

Black

Hispanic

Latino/a/x

Middle Eastern

Native American

Pacific Islander

South Asian

Southeast Asian

White

Prefer not to say

Other:

Required

I am: *

Involved in the Deaf community

Not involved in the Deaf community

Prefer not to say

I am: *

Deaf

deaf

Hard of Hearing

DeafBlind

Low Vision

Prefer not to say

Other:

Required

In general, my preferred communication mode is (ex: ASL, English, ASL/English mix, Signed English, Pro-Tactile ASL, etc.) *

Do you use any languages other than ASL and English? If yes please share which language(s):

Monday - Friday when are you available for zoom/in person meeting/recordings? *

7am-12pm

12pm-5pm

5pm-7pm

I am not available Monday - Friday

Required

Saturday & Sunday when are you available for zoom/in person meetings/recordings? *

7am-12pm

12pm-5pm

5pm-7pm

I am not available on the weekends

Required

During our interviews, questions will be asked about your life experiences in the following categories. Please select all categories you would feel comfortable sharing about: *

Legal (government forms, courtroom communication, using a lawyer, etc.)

Educational (accessing support services, understanding teachers/assignments, etc.)

Housing (finding a place to live, discrimination, refused housing, etc.)

Healthcare (medical appointments, getting interpreters, hospital visits, etc.)

Employment (applying to jobs, finding work, interview process, communication at work, discrimination, etc.)

Everyday life (adjusting to many challenges, public announcements, going to a movie, isolation, etc.)

Technology Use (VP access, texting, Zoom calls, computer access, phone apps, etc.)

COVID-19 (finding information, vaccinations, hospital visits, communicating while using masks, etc.)

911 Calls (getting services during an emergency, etc.)

Advocating for the Deaf/HoH community (promoting communication access, equity, cultural awareness...)

I do not want to share personal experiences

Required

Please share why you are interested in this project? *

In your opinion, what is the most important thing the Rochester hearing community needs to know about the Deaf/HoH community? *

Is there anything else you'd like you us to know?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms