Section A: DEMOGRAPHIC INFORMATION
Please complete all questions
1. Date of birth:
_________________
2. Gender:
Male Female
3. What is your home language? ________________
4. Position held in company: ____________________
Is it a permanent or non-permanent position? _____________________
5. In what region are you working? Please tick ONE appropriate box
North West 1 Mpumalanga 2 Gauteng 3 Kwa Zulu-Natal 4 Free State 5 Eastern Cape 6 Western Cape 7
6. Ethnic group. Please tick ONE
Black White Coloured Asian Other
7. Highest Educational level (tick ONE)
No formal schooling 1
Grade 1 - 7 2
Grade 8 – 11 3
Matric 4
Less than one year formal training 5
One to two years formal training 6
More than two years formal training 7
Completed university/technikon training 8
8. Type of Disability/Diagnosis:
9. Is your immediate line manager aware of your disability?
YES NO
UNSURE
10. Cause of disability (choose one)
Congenital/Born with it 1
Medical 2
Trauma/ Motor vehicle accident 3
Other (specify) 4
If you selected other, please specify: _______________________________________
11. How long have you been living with the disability? (e.g. 5 years and 3 months)
12. Which of the following problems do you experience as a result of your disability? Please tick ALL the options relevant to yourself
Visual problems 1
Hearing problems 2
Speech problems 3
Upper limb function (One side) 4
Upper limb function (both sides) 5
Problems with walking 6
Wheelchair bound 7
Memory problems 8
Psychiatric problems 9
Problems with thought processing and planning
10
Other (please specify) 11
13. Were you employed by the Company prior to acquiring your disability?
Yes No
14. Do you require any specific adjustment/accommodation (changes to the environment, etc.) at work to perform your job?
Yes No
If you answered yes, please specify
______________________________________________________________________
15. Have your work accommodation/adjustment needs been met? Please specify.
Yes No
__________________________________________________________________________ __________________________________________________________________________
16. Have specific evacuation procedures in case of an emergency been discussed with you?
17. How do you get to work from where you live? Please select ALL appropriate answers
Own private transport – Drive myself 1
Own private transport – Driven by someone else 2 Private lift 3 Train 4 Taxi 5 Bus 6 Walking 7 Other (specify) 8
18. Do you think that you have had the same opportunities as other people to participate in and take advantage of:
Activity YES NO
Education Employment Recreation/Leisure
Complete the following questions by indicating how often each of the following has been a barrier to your own participation in the activities that matter to you. Think about the past year, and indicate how often each item has been a problem (daily, weekly, monthly, less than monthly or never). If the problem occurs, indicate how big the problem is with regard to activities that matter to you (little problem, big problem)
19. In the past 12 months, how often has the availability of transportation been a problem to you?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
20. In the past 12 months, how often has the design and layout of your home made it difficult to do what you want or need to do?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
21. In the past 12 months, how often has the design and layout of buildings and places that you use at work made it difficult to do what you want to do or need to do?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
22. In the past 12 months, how often has the design and layout of buildings and places that you use in your community made it difficult to do what you want to do or need to do?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
23. In the past 12 months, how often has the natural environment (temperature, terrain, climate) made it difficult to do what you want or need to do?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
24. In the past 12 months, how often have other aspects of your surroundings – lighting, noise, crowds, etc. made it difficult to do what you want or need to do?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
25. In the past 12 months, how often has the information you wanted or needed not been available in a format (audio, written, computer-based, Braille, larger print, etc) you can use or understand?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
26. In the past 12 months, how often has the availability of education and training you needed been a problem for you?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
27. In the past 12 months, how often has the availability of healthcare services and medical care been a problem for you?
Daily Weekly Monthly Less than monthly
28. In the past 12 months, how often has the lack of personal equipment or special adapted
devices (hearing aids, eye glasses, wheelchair) been a problem for you? Daily Weekly Monthly Less than
monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
29. In the past 12 months, how often has the lack of computer technology been a problem for you?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
30. In the past 12 months, how often did you need someone else‟s help in your home and could not get it easily?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
31. In the past 12 months, how often did you need someone else‟s help at work and could not get it easily?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
32. In the past 12 months, how often did you need someone else‟s help in your community and could not get it easily?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
33. In the past 12 months, how often have other people‟s attitudes towards you been a problem at home?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
34. In the past 12 months, how often have other people‟s attitudes towards you been a problem at
work?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
35. In the past 12 months, how often have other people‟s attitudes towards you been a problem in
the community?
Daily Weekly Monthly Less than monthly
36. In the past 12 months, how often has a lack of support and encouragement from others in your
home been a problem?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
37. In the past 12 months, how often has a lack of support and encouragement from others at work been a problem?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
38. In the past 12 months, how often has a lack of support and encouragement from others in the
community been a problem?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
39. In the past 12 months, how often did you experience prejudice or discrimination?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
40. In the past 12 months, how often has the lack of programmes or services in the community been a problem?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
41. In the past 12 months, how often did the policies and the rules of the business make problems for you?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
42. In the past 12 months, how often education and employment programs and policies make it difficult to do what you need to or want to do?
Daily Weekly Monthly Less than monthly
Never
5 4 3 2 1
When this problem occurs, has it been a little problem, or a big problem?
Little problem Big problem
43. In the past 12 months, how often did government programmes and policies make it difficult to do what you want or need to do?
Daily Weekly Monthly Less than monthly
44. Did you require any assistance from someone to complete the questionnaire?
Yes No
If yes, please specify: ___________________________________________
45. Was the questionnaire in the format that you required?
Yes No
If no, please specify: ___________________________________________
THANK YOU FOR TAKING THE TIME TO PARTICIPATE IN THIS SURVEY
Please provide your name and contact details if you are willing to answer follow-up questions
Name: _____________________________
Telephone number: __________________