Special Education Needs Survey Template Template

1. What is your age?

The answer should be a single choice:

1. Under 18
2. 18-24
3. 25-34
4. 35-44
5. 45-54
6. 55-64
7. 65 or older

2. What is your gender identity?

The answer should be a single choice:

1. Male
2. Female
3. Prefer not to say
4. Other

3. Do you identify as a person with special education needs?

The answer should be a single choice:

1. Yes
2. No

4. If yes, what is your specific need(s)?

The answer should be a multi line text input.

5. Have you received special education services in the past?

The answer should be a single choice:

1. Yes
2. No

6. If yes, were these services helpful?

The answer should be a single choice:

1. Extremely helpful
2. Somewhat helpful
3. Not very helpful
4. Not at all helpful

7. Do you feel that your current school or educational program meets your needs as a person with special education needs?

The answer should be a single choice:

1. Yes
2. No

8. If no, what specific areas need improvement?

The answer should be a multi line text input.

9. Have you ever experienced discrimination or prejudice due to your special education needs in an educational setting?

The answer should be a single choice:

1. Yes
2. No

10. If yes, please describe your experience.

The answer should be a multi line text input.

11. Are you currently employed?

The answer should be a single choice:

1. Yes, full-time
2. Yes, part-time
3. No

12. Have you ever experienced discrimination or prejudice in the workplace due to your special education needs?

The answer should be a single choice:

1. Yes
2. No

13. If yes, please describe your experience.

The answer should be a multi line text input.

14. Do you feel that your employer provides reasonable accommodations for your special education needs?

The answer should be a single choice:

1. Yes
2. No

15. Do you feel that you have access to adequate support for your special education needs?

The answer should be a single choice:

1. Yes
2. No

16. If no, what specific types of support do you need?

The answer should be a multi line text input.

17. Have you ever accessed support services for your special education needs outside of an educational or employment setting (e.g. support groups, therapy, etc.)?

The answer should be a single choice:

1. Yes
2. No

18. If yes, were these services helpful?

The answer should be a single choice:

1. Extremely helpful
2. Somewhat helpful
3. Not very helpful
4. Not at all helpful