Disability Impact Form

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If you've experienced the loss of a service, support, or opportunity due to funding changes or cuts, please complete our form. You can submit it multiple times as new situations arise. We encourage everyone connected to the disability community to contribute—disabled individuals, researchers, healthcare providers, non-profit organizations, and allies.

*All identifying information will be removed and not shared unless we have gained explicit approval from you

For Internal Purposes Only:

The information collected in this section will be removed and not shared unless we have gained explicit approval from you.

Name *

Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Gender *

Female

Male

Non-binary

Transgender

Prefer not to say

Do you currently reside in the United States? *

Yes

Would you like to be opted into our newsletter highlighting what impacts we are seeing in the disabled community? *

Yes

For The Disability Impact Registry

The information you share here may be shared publicly but will be anonymized. None of the information you shared in the last section will be shared or connected to your responses here.

I identify as (check all that apply): *

Disabled

Non Disabled

Caretaker or Family Member of Person w/Disability

Healthcare Worker

Researcher

Innovator/Entrepreneur

Work at Organization Serving Disabled/Aging

Government Employee

Other:

Required

What I’ve lost/What has changed for me: *

Ideas for how people or organizations might support this loss:

Feel free to think outside the box here. What could we do collectively to rebuild this or innovate on it?

Did something about the delivery or experience already feel broken? If yes, what wasn’t working? What could have been improved?

[OPTIONAL] What I need now:

This could be something tangible, like a certain wheelchair or assistive technology or something more abstract. Please keep it within the realm of disability/healthcare/aging.

[OPTIONAL FOLLOW UP]: If we get an offer for this need, are you open to being connected via email with someone who might be able to help?

Yes

Maybe

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