Notes in [brackets] are for the recruiter.
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What is your gender?
- Female/ Woman
- Male/ Man
- Non-binary
- Another gender, please describe: ___ [open-ended description]
- Prefer Not to Answer
-
Do you identify as transgender?
- Yes
- No
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Which terms best describe your race or ethnicity? You may select multiple terms.
- Native American, American Indian, Alaska Native, or First Nations
- Asian
- Black or African American
- Hispanic or Latino
- Native Hawaiian or Other Pacific Islander
- White
-
If a Veteran, were you enlisted or officer?
- Enlisted
- Officer
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Do you have a diagnosis for a disability or impairment that currently applies to you? This includes difficulty with learning capabilities. [Rationale if needed: We have a few questions about any disabilities you may have. We’re asking this because one of the goals of this research is to discover how we can make services easier to use for people with disabilities.]
- Yes, I have a current diagnosis for a disability or impairment
- No, I do not currently have a diagnosis for a disability or impairment
- I prefer not to say
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[If “YES, have” response to first disability question] Which of the following describes your diagnosis for a disability or impairment? You may select multiple responses. [Record all responses]
- Blind or serious difficulty seeing, even when wearing glasses
- Deaf or serious difficulty hearing
- Serious difficulty with mobility or other physical capabilities
- Serious difficulty with learning capabilities (e.g., ADHD, dyslexia)
- Serious cognitive difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition
- A disability/impairment not listed above, please describe: ___ [Record open-ended response]
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[If “Blind or serious difficulty seeing, even when wearing glasses”] Do you consider yourself low-vision, blind, or another description? If so, which/what description?
- ___ [Record open-ended response]
-
[If “Deaf or serious difficulty hearing”] Do you consider yourself deaf/Deaf, Hard of Hearing, or another description? If so, which/what description?
- ___ [Record open-ended response]
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[If “Serious difficulty with mobility or other physical capabilities”] What symptoms, limitations, or impacts do you experience due to your motor difficulty/differences, that could potentially affect your ability to file taxes or to handle tax-related topics? Examples include writing, typing, etc.
- ___ [Record open-ended response]
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[If “Serious difficulty with learning capabilities (e.g., ADHD, dyslexia)” or “Serious cognitive difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition”] Do you identify as someone who is cognitively different? This includes, but is not limited to, persons who are non-neurotypical, have mental health issues, have had a Traumatic Brain Injury (TBI), and/or have cognitive disabilities that may impact everyday life.
- Yes
- No
- ___ [Record open-ended response]
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[If “Serious difficulty with learning capabilities (e.g., ADHD, dyslexia)” or “Serious cognitive difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition”] Below is a list of cognitive functions or actions. Please select any functions or actions that you have difficulty with, or that your cognitive difficulty or differences affect. [Record all responses]
- Memory
- Problem Solving, logic, or reasoning
- Attention
- Emotion regulation
- Reading, linguistic, and verbal comprehension. For example, understanding written or spoken letters and language.
- Math Comprehension. For example, understanding numbers, mathematical representations, or mathematical calculations.
- Visual Comprehension. For example, understanding graphs, understanding icons or pictures that communicate meaning, such as a pedestrian crossing street sign, or understanding a visual scene in real life.
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[If “YES, have” response to first disability question] Do you use assistive technology and/or adaptive strategies or personal workarounds in order to use technologies like phones, computers, smart devices, the internet, etc.? [Assistive technology, or AT for short, refers to the equipment or products designed for a person with a disability to use to augment their functional capabilities. It includes things such as screen readers, magnification, tactile grip enhancers, and more. Adaptive strategies and workarounds are techniques that people with disabilities use to improve interaction with digital tools and interfaces, such as increasing text size, reducing mouse speed, turning on or adjusting captions, and more. ]
- Yes
- No
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If yes, what type(s) of assistive tech and/or adaptive strategies do you use regularly; and what devices do you use them for? [Examples if needed: Braille reader or input device, screen reader, magnification software or settings, magnifying glass, contrast enhancement software or settings, tactile grip enhancers, voice recognition software, selection switches. Device examples if needed: Smartphone, laptop, tablet, smartwatch, etc.] [Record all responses]
- ___ [Record open-ended response]