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(gender identity)

What is your age? (required)

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Legally blind

Visual impairment / low vision

Deaf / hard of hearing

Upper extremity motor impairment

Lower extremity motor impairment

Cognitive disability (autism, learning disorder, attention deficit, etc.)

Screen reader

Screen magnifier

Refreshable braille display

Speech input

Speech-to-text output

Modified keyboard

Pointing device

Switch device

Other (specify below)

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(please describe)

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