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Thank you for joining the ADA Functional Movement!
Your input will help us to improve travel for all people with disabilities. Please complete the following survey as accurately as you can. Contact us with any questions you may have. You can save your input and come back to finish at a later time. Once you have completed the survey, you can access it through your profile by hovering over the LogIn/Sign Up option at the top of the webpage.
Demographic
Birth Date
Gender
Male
Female
Marital Status
Single (never married)
Married
Separated
Widowed
Divorced
Race
American Indian and Alaska Native
Asian
Black or African American
Hispanic/Latino/Spanish
Native Hawaiian and Other Pacific Islander
White
Other Race
Income level
Less than $25,000
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 or more
Employment Status
Employed for wages
Self-employed
Out of work and looking for work
Out of work but not currently looking for work
A homemaker
A student
Retired
Employment Status
Full Time
Part Time
Freelance
Self Employed
Contractor
Retired
Not Employed
Employment type
Agriculture, forestry, fishing and hunting, and mining
Construction
Manufacturing
Wholesale trade
Retail trade
Transportation and warehousing, and utilities
Information
Finance and insurance, and real estate and rental and leasing
Professional, scientific, and management, and administrative and waste management services
Educational services, and health care and social assistance
Arts, entertainment, and recreation, and accommodation and food services
Other services, except public administration
Public administration
Education Level
Completed some high school
High school graduate
Completed some college
Associate degree
Bachelor's degree
Completed some postgraduate
Master's degree
Disability Information
Are You Disabled?
Are You Disabled?
Yes, I am disabled
No, I am not disabled
According to the ICS: Disability is conceptualized as being a multidimensional experience for the person involved. There may be effects on organs or body parts and there may be effects on a person's participation in areas of life. Correspondingly, three dimensions of disability are recognized in ICF: body structure and function (and impairment thereof), activity (and activity restrictions) and participation (and participation restrictions). The classification also recognizes the role of physical and social environmental factors in affecting disability outcomes.
Please list all limitations related to your disability (we have provided a few examples below)
Activity Limitations | Body Functions | Body Structures | Communicating | Environmental Factors | Functional Limitations | Health Conditions | Hearing | Learning | Mental health | Movement Thinking | Participation | Personal Factors
Type of Disability
How long have you had this disability?
< 1 year
1-2 years
2-3 years
3-4 years
5+ years
Please List Any Equipment Used Daily
(click the + sign on the right of the box in order to add multiple)
Please List Any Equipment Used When Traveling
(click the + sign on the right of the box in order to add multiple)
Do You Travel With A Caregiver?
Yes
No
Travel
Frequency of Travel
1-3 Times Per Year
4-6 Times Per Year
7-10 Times Per Year
10+ Times per Year
Estimated Cost of Travel Per Year
< $1000
$1000 - $5000
$5,000 - $10,000
$50,000 - $100,000
> $100,000
All Modes of Travel Used
Select All
Car
Airplane
Train
Bus
RV
Hotel Experience
Please list your latest hotel experience, and provide your review. If you would like to add more than one hotel, you will be prompted to add another at the end of the survey.
Hotel Name
Hotel City
Hotel State
Please Rate Hotel Accessibility
5 Star
4 Star
3 Star
2 Star
1 Star
Areas In Need of Improvement Related to Accessibility
Optional Video Upload of Experience
Drop files here or
Suggestions for Improvement Related to Accessibility
Hotel Function
The following questions are related to hotel function
Please Rate Hotel Function
5 Star
4 Star
3 Star
2 Star
1 Star
Areas In Need of Improvement Related to Function
Optional Video Upload of Experience
Drop files here or
Suggestions for Improvement Related to Function
Hotel Safety
The following questions are related to hotel safety
Please Rate Hotel Safety
5 Star
4 Star
3 Star
2 Star
1 Star
Areas In Need of Improvement Related to Safety
Optional Video Upload of Experience
Drop files here or
Suggestions for Improvement Related to Safety
Hotel Staff Knowledge
The following questions are related to hotel staff knowledge
Please Rate Staff Knowledge of Helping People with Disabilities
5 Star
4 Star
3 Star
2 Star
1 Star
Areas In Need of Improvement Related to Staff Knowledge
Optional Video Upload of Experience
Drop files here or
Suggestions for Improvement Related to Staff Knowledge
Other Areas of Travel In Need of Improvement
Please list any other travel concerns below
Please Describe Any Other Travel Concerns Below:
Optional Video Upload of Experience
Drop files here or
Add Additional Travel Data By Clicking Here
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Discussion
Contact Us
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Travel Survey
Add Additional Travel Data
Hotel Experience
Please list your latest hotel experience, and provide your review. If you would like to add more than one hotel, you will be prompted to add another at the end of the survey.
Hotel Name
Hotel City
Hotel State
Please Rate Hotel Accessibility
5 Star
4 Star
3 Star
2 Star
1 Star
Areas In Need of Improvement Related to Accessibility
Optional Video Upload of Experience
Drop files here or
Suggestions for Improvement Related to Accessibility
Hotel Function
The following questions are related to hotel function
Please Rate Hotel Function
5 Star
4 Star
3 Star
2 Star
1 Star
Areas In Need of Improvement Related to Function
Optional Video Upload of Experience
Drop files here or
Suggestions for Improvement Related to Function
Hotel Safety
The following questions are related to hotel safety
Please Rate Hotel Safety
5 Star
4 Star
3 Star
2 Star
1 Star
Areas of Improvement Related to Safety
Optional Video Upload of Experience
Drop files here or
Suggestions for Improvement Related to Safety
Hotel Staff Knowledge
The following questions are related to hotel staff knowledge
Please Rate Staff Knowledge of Helping People with Disabilities
5 Star
4 Star
3 Star
2 Star
1 Star
Areas In Need of Improvement Related to Staff Knowledge
Optional Video Upload of Experience
Drop files here or
Suggestions for Improvement Related to Staff Knowledge
Other Areas of Travel In Need of Improvement
Please list any other travel concerns below
Please Describe Any Other Travel Concerns Below:
Optional Video Upload of Experience
Drop files here or
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