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*
Gender identity*
Address street 1*
Address street 2
Address street 3
Zip/postal code
*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
Preferred language
Do you need an interpreter?
Programs/services/tools I have used or am using
Choose all that apply
Disability Hub MN (formerly Disability Linkage Line) (Disability Benefits 101) (Housing Benefits 101)
HCBS waiver
Home Care (PCA, Home Health Aide, Home Care Nursing)
Program HH/ADAP (AIDS Drug Assistance Program)
Self-Directed Services (CDCS, CSG, FSG)
Senior LinkAge Line
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
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
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. *