Form: Communication Access in Health Care
ASL Video of English Text:
**Same video appears at bottom of this section!**

Thanks to a grant from The Colorado Health Foundation, Civil Rights Education and Enforcement Center (CREEC) is investigating the experience of D/deaf Coloradans' communications access to health care. A Deaf CREEC team member will conduct the survey through videophone (VP) using American Sign Language (ASL).

To identify community members who are eligible to participate in our VP survey, we need to collect some information first. CREEC wants to ensure that we survey a diverse set of people, so the below form will ask some questions about you. Your information will be kept confidential.

Your contact information - name and email - is needed for two reasons:

1) To thank you for filling out this form, we will enter you in a drawing for a chance to win a $50 Target gift card!
2) Depending on your responses, we may email you to schedule a VP appointment to answer more survey questions about communications in health care in Colorado. If you are selected for the VP survey, we will send you a $20 gift card for your participation in our project.

Please note that when we use the term "effective communication" in this pre-survey, we mean that: you or your child can fully understand communication with your health care provider, and the health care provider can fully understand you or your child.

When we use the term "health care provider," we mean: anyone working in a medical setting that is providing you or your child with health care services, such as a doctor, specialized doctor like OB-GYN or oncologist, nurse, physician’s assistant, internist, etc. This also includes people who work for health care providers, like front desk staff or receptionists at a medical office.

If you have questions about this project, please contact Amy Robertson at
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