Survey Last four digits of your social security number: County you live in: Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington Please check the type of area you live in: Rural Urban/City Small Town/Suburb No Answer Please check the type of household you live in: Single Parent Two Parent Other No Answer Number of adults in the household , and total number with disability . Number of children in the household , and total number with disability . Number of teenagers/young adults in the household , and total number with disability .   1. Does anyone have the following disabilities and/or special health care needs:   Disability Age Months   Disability Age Months ADHD/ADD   Behavioral Disorder (severe) Autism   Developmental Delay Allergies (severe)   Mental Disability/Delay Asthma (severe)   Physical Disability/Delay Cystic Fibrosis   Speech/Language Delay Diabetes   Hearing Impairment Sickle Cell Anemia   Vision Impairment   Other medical condition(s) requiring speacial attention (please indicate):   2. What is your occupation?   For example: Bookeeper, Plumber, Press Operator, Administrator, etc.   3. Has having a child, teenager, young adult, self-advocate with a disability affected your job advancement?   Yes   No     If yes, please check which of the following may apply: Did you have to change to a job with fewer hours? Did you keep the same job but request fewer hours? Turned down job advancement due to the need for very flexible hours.  Is your employer aware of your family's disability or speacial health care situation? Yes   No   No Answer