Demographic Information Form

Demographic Information Form
Why we collect this information

DRIVEN NeuroRecovery Center is a program of the non-profit organization, Conquer Paralysis Now. We use demographic information for grant applications, donor reporting, sponsorship opportunities, and other funding purposes. Your responses help us secure resources to continue providing services.

Providing this information is voluntary, and you may select multiple options, “Other”, or “Prefer Not to State” where applicable.
Spinal Cord InjuryStrokeTraumatic Brain InjuryTransverse MyelitisMultiple SclerosisPrefer Not to StateOther
Year of Primary Diagnosis or Injury
MaleFemaleTransgender MaleTransgender FemaleNon-BinaryPrefer Not to StateOther
Active MilitaryVeteranFirst ResponderNonePrefer Not to State
Preferred Spoken Language
Number of People in Your Household
Total Household Income (Annual)
Healthcare and Rehabilitation FacilityCommunity OrganizationOnline and Social MediaDrive-By DRIVEN FacilityDRIVEN Staff or Board memberOther DRIVEN ClientPrefer Not to StateOther
Please indicate the specific facility, organization, website/app, or DRIVEN client where you first learned about DRIVEN:
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderWhite (Not of Hispanic or Latino Descent)Prefer Not to StateOther
Drives own vehicleDriven by family/caregiver in their vehicleRideshare (Uber/Lyft or similar)RTC (including RTC ParaTransit)Prefer Not to StateOther
Consent for Data Use

I understand that my demographic information will be used by DRIVEN staff only as necessary to provide care. Some data may be used for grant applications, donor reporting, sponsorship opportunities, and other funding purposes. Your name will not be used in conjunction with demographic data. For these purposes, we will use either summarized demographic data for all clients or anonymize it so that personally identifiable information is removed. By signing below, I consent to the use of my data as described.
DRIVEN Client Name*

First NameLast Name
Designated Signer Name (if applicable)

First NameLast Name
Parent/Guardian Name (for minors under the age of 18) (if applicable)

First NameLast Name
Client, Parent/Guardian, or Designated Signer's Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Demographic Information Form

Consent for Data Use