Virtual Insight Panel application
Please tell us more about you. Fields marked with an asterisk (*) are required.
 
Contact Information
 
First name*
 
 
 
 
Middle name
 
 
 
 
Last name*
 
 
 
 
Birthday*
 
 
 
 
Gender identity*
 
 
 
 
Address street 1*
 
 
 
 
Address street 2
 
 
 
 
Address street 3
 
 
 
 
City*
 
 
 
 
State/province*
 
 
 
 
Zip/postal code
 
 
 
 
Email*
 
 
 
 
*Note: If you do not have an email address, this will limit your VIP participation options.
Primary phone*
 
 
 
 
Preferred contact method
 
 
 
 
About Me
 
 
 
 
I identify as having a disability
 
 
 
I am a parent/family member/friend who supports a person who identifies as having a disability
 
 
I identify with the following disabilities
 
Choose all that apply
 
 
 
 
Autism spectrum
 
 
 
 
Blindness/low vision
 
 
 
 
Brain injury
 
 
 
 
Chemical dependency
 
 
 
 
Chronic health condition
 
 
 
Chronic health condition comments
 
 
 
 
Deaf or hard of hearing
 
 
 
 
Developmental disability
 
 
 
 
Intellectual disability
 
 
 
 
Learning disability
 
 
 
 
Mental health
 
 
 
 
Physical or mobile disability
 
 
 
Speech or language disability
 
 
 
Temporary disability
 
 
 
 
Other disability
 
 
 
 
Other comments
 
 
 
 
I identify with the following race/ethnicities
 
Choose all that apply (must select at least one)
 
 
 
 
Non-Hispanic White, European or Euro-American
 
 
 
Black, Afro-Caribbean, African or African-American
 
 
 
Hispanic, Chicano or Latino
 
 
 
 
Asian and Pacific Islander
 
 
 
 
Middle Eastern or Arab-American
 
 
 
Native American, American Indian or Alaskan Native
 
 
 
Prefer not to disclose
 
 
 
 
Other
 
 
 
 
 
 
 
Preferred language
 
 
 
 
Do you need an interpreter?
 
 
 
Guardianship
 
 
 
 
Programs/services/tools I have used or am using
 
Choose all that apply
 
 
 
 
Disability Hub MN (formerly Disability Linkage Line)
 
 
 
DB101.org (Disability Benefits 101)
 
 
 
DirectSupportConnect.com
 
 
 
 
HB101.org (Housing Benefits 101)
 
 
 
HCBS waiver
 
 
 
 
Home Care (PCA, Home Health Aide, Home Care Nursing)
 
 
 
MinnesotaHelp.info
 
 
 
 
Program HH/ADAP (AIDS Drug Assistance Program)
 
 
 
Self-Directed Services (CDCS, CSG, FSG)
 
 
 
Senior LinkAge Line
 
 
 
 
VetLink
 
 
 
 
No programs/services/tools used or am using
 
 
 
Types of activities that you want to participate in:
Choose all that apply
 
 
 
 
Focus groups in person
 
 
 
 
Focus groups with online presentation
 
 
 
Focus group phone conferences
 
 
 
Interview phone conferences
 
 
 
Interviews in person
 
 
 
 
Interviews with online presentation
 
 
 
Surveys/polls
 
 
 
 
Technology
 
 
Choose all that apply
 
 
 
 
Computer/tablet in home with internet/email
 
 
 
Computer/tablet in home but not internet
 
 
 
Internet/email in a public space
 
 
 
Smart phone with internet/email
 
 
 
Smart phone without internet/email
 
 
 
Telephone
 
 
 
 
Referral
 
 
Did someone refer you to apply for the VIP?
 
 
 
 
Referral first name
 
 
 
 
Referral last name
 
 
 
 
 
 
 
I agree to the terms and conditions*
 
 
 
 
 
 
 
 
 
* Please select at least one ethnicity or choose prefer not to disclose. *