You must have JavaScript enabled to use this form. 1 2 IntroductionASL Video Referring People to ASL Questionnaire This questionnaire is available with American Sign Language. If you would like to complete this questionnaire using ASL, please use this link: 911 Emergency Services Questionnaire in ASLThe best way to contact 911 is by phone. This may not always work. There are times when we cannot talk. We may have talking problems. There are times when it is not safe to talk. We may be robbed. We want to change this with Next Generation 911 (NG911). This will give us more ways to talk to 911. We will be able to use voice, text, and video to chat. This will let us get help safe and fast. Please answer the questions below. It will help us see if you are a good fit for the focus groups we have coming up to discuss this subject. The questionnaire should only take a few minutes. Do you want to do it over the phone? If you do, please email us. Our email address is rd.info@neilsquire.ca. We will set a time up to ask you the questions. Principal Investigator:Dr. Gary Birch Executive DirectorNeil Squire Society Head of Research and Development Email: garyb@neilsquire.ca What if I don't understand something?The questions may have words you do not understand. If you would like, the research staff will read it with you. You can arrange to have the staff help you complete the questions by emailing rd.info@neilsquire.ca.You are free to ask questions at any time – before, during, or after you complete the questions.Please ask as many questions as you would like before you decide if you want to be considered for the study. If you decide to complete the questions, it should be because you really want to volunteer. Questionnaire Procedures The questions will take about 15 minutes to answer. Study TeamThis study is being conducted by a research team led by Dr. Gary Birch. If you have any questions or need help in completing the questions, please email our project team at: rd.info@neilsquire.ca. Risks and Benefits of ParticipationThere are no known or suspected risks associated with answering the questions. ConfidentialityWe respect your privacy and are committed to protecting the personal information that we collect from you. We will: only collect the information required give you access to your own records and, if requested, make copies of them at a reasonable cost ask your permission to share your information if required for other purposes unless we must provide it for legal reasons keep your information safe keep accurate records. ConsentAnswering the questions is entirely voluntary. You may refuse to answer or withdraw at any time. There will be no penalty if you choose not to complete the questions or if you start to answer and then change your mind. By answering the questions below and clicking the SUBMIT button you indicate that you have understood the information above and agree to participate. If you have any concerns or complaints about your rights as a research participant and/or your experiences while completing this questionnaire, contact Dr. Gary Birch at garyb@neilsquire.ca. Contact InformationPlease provide the following contact information. What is your full name? * What is your contact email? * What province/territory are you in? * - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonMobility-Related ConditionsIf you cannot freely move your fingers, hands or arms please answer these questions. Can you spread your arms wide as if you were opening a large newspaper? I can spread my arms alll the way I can spread my arms part of the way No, I cannot spread my arms at all Can you hold a pen in your hand and write your name without a writing aid? I can hold a pen No, I cannot hold a pen Can you hold a 12-ounce cup of coffee in front of you with your arms fully extended for 10 seconds? I can hold a 12-ounce cup of coffee in front of me with my arms fully extended for 10 seconds No, I cannot hold a 12-ounce cup of coffee in front of me with my arms fully extended for 10 seconds Do you use a walking aid? I use a cane or crutch I use a walker I use a manual wheelchair I use a power wheelchair I do not use a walking aid Hearing-Related ConditionsIf you have difficulty hearing, please answer these questions. Do you have problems hearing a conversation with someone in a crowded room? I have problems hearing a conversation with someone in a crowded room No, i do not have problems hearing a conversation with someone in a crowded room Do you use a hearing aid? I use a hearing aid No, I do not use a hearing aid Are you Deaf? I am Deaf No, I am not Deaf Vision-Related ConditionsIf you have difficulty seeing, please answer these questions. Do you need to be less than 1 block away to read the letters on a stop sign? I need to be less than 1 block away to read the letters on a stop sign No, I do not need to be less than 1 block away to read the letters on a stop sign Do you have partial vision loss? I have partial vision loss No, I do not have partial vision loss If you have partial vision loss, can you read the display of a mobile phone with the accessibility features enabled? I can read the display of a mobile phone with the accessibility features enabled No, I cannot read the display of a mobile phone with the accessibility features enabled Do you have total vision loss? I have total vision loss No, I do not have total vision loss Cognitive or Intellectual Disability-Related ConditionsIf you have difficulty concentrating, remembering or following instructions please answer these questions. Are you a person with a cognitive condition or intellectual disability? I am a person with a cognitive condition or intellectual disability No, I am not a person with a cognitive condition or intellectual disability Everyone, please answer the following questions.Technical Use: Do you own a mobile device (cell phone)? I own a mobile device No, I do not own a mobile device Is your mobile device an Android or Apple iOS device? My mobile device is an Android My mobile device is an Apple IOS I do not know what kind of mobile device I have Did you get the mobile device (cell phone) in the last 3 years? Yes, I got my mobile device (cell phone) in the last 3 years No, I did not get my mobile device (cell phone) in the last 3 years Do you need accessibility aids to use the mobile device? Yes, I need accessibility aids No, I do not need accessibility aids If you use accessibility aids, what aids do you use? Would you call yourself a novice, intermediate, or expert mobile device user? I am a Novice mobile device user I am a Intermediate mobile device user I am an Expert mobile device user Emergency Services Use Have you contacted 911 emergency services before? * Yes, I have contacted 911 emergency services No, i have not contacted 911 emergency services How long ago did you contact 911? How did you contact 911? Other Question Do you want us to ask for your help in the future? Yes, please contact me in the future so I can offer my help No, please do not contact me in the future Leave this field blank CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Next Page >
