Survey on Use of Medical Equipment (Consent Disclaimer) Introduction Thank you for thinking about being involved in this study. It is being done by the Rehabilitation Engineering Research Center (RERC) on Accessible Medical Instrumentation. The study is being led by Dr. Jill Winters, from Marquette University's College of Nursing in Milwaukee, WI. Your Participation in the Survey The reason we have asked you to complete this survey is that we want to learn more about what types of medical equipment you may have found hard to use, or you think might present problems for you to use. Later, we will make changes to some equipment, making them easier for people with disabilities to use. If you finish part or all of this survey, it means you understand how we will use the information you give us and you agree to take part in this study. Completing part or all of this survey is voluntary, and you can stop answering questions at any time, without penalty. Your identity will not be shared with anyone, and your answers will not be linked to your name in any way. This site is password protected, so no one other than the researchers will have access to your information. Your name will not appear anywhere on the data we collect. About 200 healthcare providers, with and without disabilities, will participate in this study. Benefits and Risks of Participation There are no direct personal benefits to you for filling out this survey. It will take about 30 to 90 minutes to finish. Although we don't expect any risks, there is a small chance you may get tired when completing the survey. Therefore, if you need to take a break, please do so. Authorization for Use and Disclosure of Protected Health Information Completing this survey will involve your protected health information. You will be asked to provide information about your age, current state of health, and types of disability. This information will be stored in a password-protected computer and will only be available to Dr. Winters and the research team. No information will be collected that identifies you or connects you to the data you give us. The health information you give us will help us find problems that healthcare providers have had with some medical devices. Reports will be shared with the public that describe the types of people who took part in the survey, and the problems they have had with some medical devices. Your information will be combined with everyone else's data. No information will be shared about individual people. This information will be kept secure until December 31, 2008, when it will be destroyed. The private health information you provide may be reviewed by officials, in order to meet federal or state rules. Reviewers may include representatives from the Department of Health and Human Services, the Marquette University Institutional Review Board, and/or the Western University of Health Sciences Institutional Review Board. You have the right to withdraw your permission/authorization, in writing, at any time. To withdraw, contact Dr. Jill Winters at the address at the bottom of this page, or by e-mail at jill.winters@marquette.edu, and let her know you are withdrawing your permission to use your protected health information. All of the health information you have already submitted as part of the study will continue to be used, but no new information about you will be collected. You may make a copy of these instructions for your records. Returning this survey shows that you agree to have your personal health information shared with the research team and used as described above. Contact the Researchers You may ask questions of the research staff at any time during the study by contacting: Erin Schwier Center for Disability Issues and the Health Professions Western University of Health Sciences 309 E. 2nd Street Pomona, CA 91766-1854 Phone: (800) 832-0524 E-mail: info@rerc-ami.org Technical Assistance If you have any difficulty accessing or completing the survey or submitting the completed survey, please contact: Erin Schwier E-mail: info@rerc-ami.org Telephone: (800) 832-0524 Getting Started The purpose of this survey you are filling out is to help us learn about difficulties that some people with disabilities have had using some medical equipment, such as devices used for diagnosing and treating medical problems. Thank you for helping us with this very important project! R1.2 National Survey Questions - Part 1 / Personal We need to collect personal information about you so that we can compare the results we get on this survey to the results of other similar surveys, like the U.S. Census and the National Health Interview Survey (NHIS). Please mark the box next to your answer to each of the following questions. Please mark only one answer unless the instructions say you may mark more than one. 1. Do you currently work? No Yes, usually part time - On average, how many hours per week? _____ Yes, usually full time (40 or more hours per week) 2. What type of medical profession are you affiliated with? Physician Physician's Assistant Nurse Practitioner Clinical Nurse Specialist Registered Nurse Licensed Practical/Vocational Nurse Nursing Assistant Physical Therapist Occupational Therapist Respiratory Therapist Speech Therapist X-Ray Technician Dentist Dental Assistant Other - Please specify _____ I choose not to answer 3. What is your area of specialization? Cardiology Community Health Ear, Nose, & Throat Emergency/Urgent Care Endocrinology Gastroenterology General Medicine Gerontology Home Health Neurology Nephrology Neurosurgery Obstetrics/Gynecology Oncology Ophthalmology/Optometry Orthopedics Pediatrics Physical Medicine and/or Rehabilitation Psychiatry Psychology Public Health Pulmonary Radiology Rheumatology Surgery Other - Please specify _____ 4. In what U.S. state do you practice? _____ 5. Where is your medical facility located? Rural community Suburb City R1.2 Questions - Part 2 / Equipment The reason we have asked you to complete this survey is we want to learn more about what kinds of medical equipment have been difficult for healthcare providers, with or without disabilities, to use when providing care for a variety of individuals, including people who have disabilities. Later, we will make changes to some of the identified equipment to make those devices easier to use. The next section of the survey asks about your past experiences using various types of medical instrumentation and assistive technologies. There are four categories: * Procedural equipment * Diagnostic equipment * Therapeutic equipment * Assistive technologies, used either as or with medical equipment You may have used some of these types of equipment at a medical clinic, hospital, or a person's home. We are interested in knowing about all the experiences you have had, in any location. Please consider the difficulties you have had using the equipment yourself, or when teaching a patient or family member to use the equipment. Which of these types of equipment have you had experience using? (You will be asked to provide answers to questions only in these areas.) Examination Tables Medical/Examination/Procedure Chairs Dental Equipment Eye Exam Equipment Hearing Test Equipment X-ray Equipment Cardiac Stress Test Equipment Pulmonary Function Test Equipment Rehabilitation Equipment Exercise Equipment Medication Administration Equipment Respiratory/Oxygen Equipment Monitoring Equipment (e.g., blood pressure, ECG, glucometer, INR, etc.) Weight Scales Mobility Aids Communication Equipment (e.g., keyboard, mouse, monitor, personal digital assistant [PDA], telephone, cell phone, communication board, augmentative communication device, assistive listening system, etc.) Electronic Healthcare Records Other - Please specify _____ Questionnaire Please indicate the experiences you have had with these types of medical equipment, if any, when caring for patients. Please feel free to elaborate on any items you select. Your feedback is greatly appreciated. Type of Medical Equipment: Examination Tables Your experience with Examination Tables: Little Moderate Frequent Extensive Your difficulty or discomfort with Examination Tables: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Examination Tables? Too high - Please describe: _____ Too low - Please describe: _____ Too narrow - Please describe: _____ Too long - Please describe: _____ Too short - Please describe: _____ Too hard - Please describe: _____ Too soft - Please describe: _____ Problems with stirrups - Please describe: _____ Problems with positioning - Please describe: _____ Problems with transferring - Please describe: _____ Problems with step - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Examination Tables? (Please describe.) _____ Move to next category of equipment you have had experience using. Type of Medical Equipment: Medical/Examination/Procedure Chairs (e.g., dental, oral surgery, eye exam, laboratory, reclining procedure chairs [chemotherapy, dialysis, transfusion, etc.]) Your experience with Chairs: Little Moderate Frequent Extensive Your difficulty or discomfort with Chairs: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Chairs? Too high - Please describe: _____ Too low - Please describe: _____ Too narrow - Please describe: _____ Too long - Please describe: _____ Too short - Please describe: _____ Too hard - Please describe: _____ Too soft - Please describe: _____ Problems with positioning - Please describe: _____ Problems with transferring - Please describe: _____ Problems with step - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Chairs? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: Dental Equipment (e.g., x-ray equipment, drills, etc.) Your experience with Dental Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Dental Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Dental Equipment? Bite wings not proper sizes - Please describe: _____ X-ray equipment - Please describe: _____ Height of spittoon - Please describe: _____ Latex sensitivity - Please describe: _____ Instrument sizes - Please describe: _____ Lighting - Please describe: _____ Problems with suctioning - Please describe: _____ Problems with positioning - Please describe: _____ Problems with transferring - Please describe: _____ Problems with keeping patient's mouth open - Please describe: _____ Problems with dental chairs - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Dental Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using. Type of Medical Equipment: Eye Exam Equipment (e.g., vision test, glaucoma test, peripheral vision test, etc.) Your experience with Eye Exam Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Eye Exam Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Eye Exam Equipment? Problems with tonometry - Please describe: _____ Problems with gonioscopy - Please describe: _____ Problems with slit lamps - Please describe: _____ Problems with retinal cameras - Please describe: _____ Problems with topographers - Please describe: _____ Problems with lighting - Please describe: _____ Problems with adjusting chin rests - Please describe: _____ Problems with positioning - Please describe: _____ Problems with transferring - Please describe: _____ Problems with eye exam chairs - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Eye Exam Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using. Type of Medical Equipment: Hearing Test Equipment (e.g., headphones, soundproof booth, etc.) Your experience with Hearing Test Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Hearing Test Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Hearing Test Equipment? Soundproof booth too small - Please describe: _____ Problems getting into soundproof booth - Please describe: _____ Problems with communication - Please describe: _____ Problems with headphones - Please describe: _____ Problems with lighting - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Hearing Test Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: X-Ray Equipment (e.g., general x-ray, MRI, CT scan, PET scan, mammogram, bone density scan, ultrasound, radiation therapy, etc.) Your experience with X-Ray Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with X-Ray Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using X-Ray Equipment? Too high - Please describe: _____ Too low - Please describe: _____ Too narrow - Please describe: _____ Too long - Please describe: _____ Too short - Please describe: _____ Too hard - Please describe: _____ Problems with positioning - Please describe: _____ Problems with transferring - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using X-Ray Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: Cardiac Stress Test Equipment Your experience with Cardiac Stress Test Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Cardiac Stress Test Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Cardiac Stress Test Equipment? Problems with treadmill - Please describe: _____ Problems with cycle ergometer - Please describe: _____ Problems with electrodes - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Cardiac Stress Test Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: Pulmonary Function Test Equipment Your experience with Pulmonary Function Test Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Pulmonary Function Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Pulmonary Function Test Equipment? Problems reading displays - Please describe: _____ Problems with transferring - Please describe: _____ Problems with positioning - Please describe: _____ Problems with mouthpieces - Please describe: _____ Problems getting into booth - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Pulmonary Function Test Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: Rehabilitation Equipment (e.g., cardiac, pulmonary, occupational therapy, physical therapy) Your experience with Rehabilitation Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Rehabilitation Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Rehabilitation Equipment? Too high - Please describe: _____ Too low - Please describe: _____ Problems with treadmill - Please describe: _____ Problems with cycle ergometer - Please describe: _____ Problems with hand bike - Please describe: _____ Problems with weights/weight machines - Please describe: _____ Problems with tables - Please describe: _____ Problems with mats - Please describe: _____ Problems transferring - Please describe: _____ Problems positioning - Please describe: _____ Problems reading displays - Please describe: _____ Problems with touch screens - Please describe: _____ Problems with assistive devices - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Rehabilitation Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using. Type of Medical Equipment: Exercise Equipment (e.g., exercise bike, treadmill, parallel bars, exercise mats, free weights, weight machines, etc.) Your experience with Exercise Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Exercise Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Exercise Equipment? Too high - Please describe: _____ Too low - Please describe: _____ Problems with treadmill - Please describe: _____ Problems with cycle ergometer - Please describe: _____ Problems with hand bike - Please describe: _____ Problems with weights/weight machines - Please describe: _____ Problems with tables - Please describe: _____ Problems with mats - Please describe: _____ Problems transferring - Please describe: _____ Problems positioning - Please describe: _____ Problems reading displays - Please describe: _____ Problems with touch screens - Please describe: _____ Problems with assistive devices - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Exercise Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: Medication Administration Devices (e.g., IV infusion pumps, syringes, etc.) Your experience with Medication Administration Devices: Little Moderate Frequent Extensive Your difficulty or discomfort with Medication Administration Devices: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Medication Administration Devices? Problems with reading markings on syringes - Please describe: _____ Problems with reading displays - Please describe: _____ Problems with touch screens - Please describe: _____ Problems with manipulating equipment - Please describe: _____ Problems with reading labels - Please describe: _____ Problems hearing alarms - Please describe: _____ Problems opening pill bottles - Please describe: _____ Problems with removing medications from packaging - Please describe: _____ Problems with pill cutters - Please describe: _____ Problems with dial-a-flows - Please describe: _____ Problems with IV poles - Please describe: _____ Problems with IV pumps - Please describe: _____ Problems with syringes - Please describe: _____ Problems with self-injection in areas not easily accessible - Please describe: _____ Problems with insulin pens - Please describe: _____ Problems with insulin pumps - Please describe: _____ Problems with eye droppers - Please describe: _____ Problems with inhalers - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Medication Administration Devices? (Please describe.) _____ Move to next category of equipment you have had experience using. Type of Medical Equipment: Respiratory/Oxygen Equipment (e.g., ventilators, oxygen delivery devices, nebulizers, suction devices, etc.) Your experience with Respiratory/Oxygen Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Respiratory/Oxygen Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Respiratory/Oxygen Equipment? Problems with touch screens - Please describe: _____ Problems with reading displays - Please describe: _____ Problems with manipulating equipment - Please describe: _____ Problems with noise - Please describe: _____ Problems with portability - Please describe: _____ Problems with weight of equipment - Please describe: _____ Problems with sterilizing/cleaning equipment - Please describe: _____ Problems with connecting/disconnecting tubing - Please describe: _____ Problems with changing settings - Please describe: _____ Problems with plugging in equipment - Please describe: _____ Problems with changing batteries - Please describe: _____ Problems with setting/disarming alarms - Please describe: _____ Problems with hearing alarms - Please describe: _____ Problems with masks - Please describe: _____ Problems with nasal cannulas - Please describe: _____ Problems with CPAP - Please describe: _____ Problems with nasal ventilators - Please describe: _____ Problems with regulators - Please describe: _____ Problems with opening and measuring medications for nebulizers - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Respiratory/Oxygen Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using. Type of Medical Equipment: Monitoring Equipment (e.g., glucometer, spirometer, pulsoximeter, heart monitor, blood pressure cuff, thermometer, stethoscope etc.) Your experience with Monitoring Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Monitoring Equipment: None Little Moderate Extreme Impossible Which of the following have you experienced when using Monitoring Equipment? Procedures too complicated - Please describe: _____ Buttons too small - Please describe: _____ Mobility restriction - Please describe: _____ Problems with touch screens - Please describe: _____ Problems with reading displays - Please describe: _____ Problems with displays disappearing too quickly - Please describe: _____ Problems with manipulating equipment - Please describe: _____ Poorly fitting blood pressure cuffs - Please describe: _____ Blood pressure difficult to obtain with one hand - Please describe: _____ Blood pressure tubing too short - Please describe: _____ Problems with calibration - Please describe: _____ Problems with plugging in equipment - Please describe: _____ Problems with changing batteries - Please describe: _____ Problems with setting/disarming alarms - Please describe: _____ Problems with hearing alarms - Please describe: _____ Problems with getting good seal on ear thermometers - Please describe: _____ Problems with getting blood on testing strips correctly - Please describe: _____ Problems with latex sensitivity - Please describe: _____ Problems with using lancets - Please describe: _____ Problems with electrodes - Please describe: _____ Problems with lead wires - Please describe: _____ Problems with pulsoximeters - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Monitoring Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using. Type of Medical Equipment: Weight Scales (e.g., standing, chair, wheelchair, bed, etc.) Your experience with Weight Scales: Little Moderate Frequent Extensive Your difficulty or discomfort with Weight Scales: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Weight Scales? Too high - Please describe: _____ Too low - Please describe: _____ Too narrow - Please describe: _____ Problems with balance - Please describe: _____ Problems with standing - Please describe: _____ Problems with positioning - Please describe: _____ Problems with transferring - Please describe: _____ Problems with step - Please describe: _____ Problems with accuracy - Please describe: _____ Problems with capacity - Please describe: _____ Problems with visual display - Please describe: _____ Problems with standing scale - Please describe: _____ Problems with chair scale - Please describe: _____ Problems with wheelchair scale - Please describe: _____ Problems with sling scale - Please describe: _____ Problems with bed scale - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Weight Scales? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: Mobility Aids (e.g., cane, walker, crutches, wheelchair, scooter, transfer/lift equipment, etc.) Your experience with Mobility Aids: Little Moderate Frequent Extensive Your difficulty or discomfort with Mobility Aids: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Mobility Aids? Unable to properly fit - Please describe: _____ Unstable - Please describe: _____ Too high - Please describe: _____ Too low - Please describe: _____ Too wide - Please describe: _____ Too narrow - Please describe: _____ Too heavy - Please describe: _____ Too bulky - Please describe: _____ Too hard to use - Please describe: _____ Too noisy - Please describe: _____ Cumbersome - Please describe: _____ Not sturdy enough - Please describe: _____ Can't use without hands - Please describe: _____ No head support - Please describe: _____ Not visible enough - Please describe: _____ Problems with balance - Please describe: _____ Problems with stability - Please describe: _____ Problems with cushions - Please describe: _____ Problems with positioning - Please describe: _____ Problems with transferring - Please describe: _____ Problems with back support - Please describe: _____ Problems with maneuvering - Please describe: _____ Problems with handles - Please describe: _____ Problems with carrying things - Please describe: _____ Problems with changing batteries - Please describe: _____ Problems with re-charging - Please describe: _____ Problems with stability on wet pavement - Please describe: _____ Problems with foot supports - Please describe: _____ Problems with maintenance/repairs - Please describe: _____ Problems with flat tires - Please describe: _____ Problems with brakes - Please describe: _____ Problems with durability/dependability - Please describe: _____ Problems with controls - Please describe: _____ Problems with keeping clean - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Mobility Aids? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: Communication Equipment (e.g., keyboard, mouse, monitor, personal digital assistant [PDA], telephone, cell phone, communication board, augmentative communication device, assistive listening system, etc.) Your experience with Communication Equipment: Little Moderate Frequent Extensive Your difficulty or discomfort with Communication Equipment: None Little Moderate Extreme Impossible Which of the following have you/your patients experienced when using Communication Equipment? Procedures too complicated - Please describe: _____ Buttons/keys too small - Please describe: _____ Mobility restriction - Please describe: _____ Problems with speech recognition - Please describe: _____ Problems with others understanding you - Please describe: _____ Problems with hearing - Please describe: _____ Problems with touch screens - Please describe: _____ Problems with reading displays - Please describe: _____ Problems with displays disappearing too quickly - Please describe: _____ Problems with manipulating equipment - Please describe: _____ Problems with grasping/holding - Please describe: _____ Problems with keyboards - Please describe: _____ Problems with computer mice - Please describe: _____ Problems with computer monitors - Please describe: _____ Problems with personal digital assistants (PDAs) - Please describe: _____ Problems with telephones - Please describe: _____ Problems with cell phones - Please describe: _____ Problems with TTY lines - Please describe: _____ Problems with software - Please describe: _____ Problems with communication boards - Please describe: _____ Problems with augmentative communication devices - Please describe: _____ Problems with assistive listening system - Please describe: _____ Too heavy - Please describe: _____ Too bulky - Please describe: _____ Too hard to use - Please describe: _____ Too noisy - Please describe: _____ Cumbersome - Please describe: _____ Not sturdy enough - Please describe: _____ Can't use without hands - Please describe: _____ Problems with maintenance/repairs - Please describe: _____ Discomfort - Please describe: _____ Unsafe - Please describe: _____ Other - Please describe: _____ What changes might be made to improve the ease and/or comfort of using Communication Equipment? (Please describe.) _____ Move to next category of equipment you have had experience using Type of Medical Equipment: Other - Please specify: _____ Your experience with Other Devices: Little Moderate Frequent Extensive Your difficulty or discomfort with Other Devices: None Little Moderate Extreme Impossible Which of the following have you experienced when using (other equipment)? Please describe: _____ Please describe: _____ Please describe: _____ Please describe: _____ Please describe: _____ Please describe: _____ What changes might be made to improve the ease and/or comfort of using (other equipment)? (Please describe.) _____ Do you have any other comments about medical instrumentation? _____ If you have a disability, does the design of the medical equipment with which you work limit your ability to care for patients/clients? If so, please share some of your thoughts/experiences about this with us. _____ R1.2 National Survey Questions - Part 3 / Personal 1. What sex are you? Female Male 2. How old are you? 18-24 years old 25-44 years old 45-64 years old 65-74 years old 75 years or older 3. Are you Spanish/Hispanic/Latino? No Yes, Mexican, Mexican-American, or Chicano Yes, Puerto Rican Yes, Cuban Yes, other Spanish/Hispanic/Latino (Please specify): _____ 4. What race are you? (Please mark all that apply) White Black or African American American Indian or Alaska Native (Please enter name of enrolled or principal tribe): _____ Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian (Please specify): _____ Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander (Please specify): _____ Some other race (Please specify): _____ 5. What condition(s) do you have? (Please mark all that apply.) Vision impairment Hearing impairment Speech impairment Orthopedic impairment Back or spine condition Arthritis or rheumatism Absence or loss of arm or leg Traumatic brain injury (head injury) Spinal cord injury Paralysis Cerebrovascular disease (including stroke) Cerebral palsy Parkinson's disease Myasthenia Gravis Multiple Sclerosis Muscular dystrophy Chronic pain Learning disability Mental retardation Other developmental disability Alzheimer's disease or other dementia Frequent depression Frequent anxiety Schizophrenia Other psychiatric disability Heart condition High blood pressure Lung or respiratory condition Diabetes Cancer Latex sensitivity Other severe allergy or sensitivity (Please specify) _____ Other (Please list) _____ I do not have a condition that causes me difficulty 6. Do you have difficulties with: (Please check all that apply.) Reaching Grasping Pinching Twisting your wrist Pushing buttons Shaking/tremor Feeling shapes/surfaces Feeling hot and cold Feeling sharp and dull None 7. Do you ever use any of the following? (Please mark all that apply.) Cane, crutches, or walker Manual wheelchair Powered wheelchair, electric scooter, or similar aid Eyeglasses (for distance or reading) or contact lenses Hearing aid Other: _____ None After you have completed this form on your computer, you may send it as an attachment to an email message to: survey2@rerc-ami.org Or, you may send it on disk by mail to: Jill M. Winters, PhD, RN Marquette University College of Nursing P.O. Box 1881 Milwaukee, WI 53201-1881 Thank you for participating in our project! If you would be willing to be contacted for future research in this area, please provide us with your name, address, telephone number, and/or e-mail address below. This information will not be filed with the information you provided on this survey. It will automatically be re-directed to another secure, password protected file. We will not access this information until after this survey has been completed and results have been analyzed. Name: _________________________________________ Address: _________________________________________ _________________________________________ _________________________________________ Telephone: _________________________________________ E-mail: _________________________________________