Candidate Name: _________________________________________

Campaign Manager: ______________________________________

Phone: __________________ Fax: _________________________

Campaign Name: _________________________________________

Campaign Address: ________________________________________

Contact Person: _________________________________________

Phone: __________________ Fax: _________________________

Email: ___________________ Website: _____________________

1. Is your campaign headquarters accessible to persons with disabilities? If you are in private practice, is your office accessible to persons with disabilities?

    

    

2. Please describe any experience with disability you have had in your life or career.

    

    

3. How will you incorporate people with disabilities into your campaign?

    

    

4. Are you willing to hire and use flex-time and job-sharing if necessary?

    

    

5. While in public office/prior to this campaign, what have you accomplished in regard to advancing disability rights? This can include work towards accessible housing, transportation, employment, health care, education, and including people with disabilities in the political process?

    

    

6. What special accommodations do you believe/think are in use in the workplace?

    

    

7. Will you commit to only attend or sponsor events that are accessible to people with disabilities? This includes providing written materials in alternate formats for people with low vision, providing assistive listening systems for people who are hard-of-hearing, and sign language interpreters for people who are deaf, as well as ensuring that locations are accessible to people who use mobility aids, like wheelchairs and walkers?

    

    

8. How do you propose your active involvement/availability to the disability community? Will there be a specific person in your office responsible to this community? Will have regular office agenda meetings on these issues? What would you do to have direct contact with our community?

    

    

9. Persons with disabilities have historically been under-represented within the Democratic Party leadership. According to the 2000 census, persons with disabilities comprised 20.6% of all residents in New York State and 23.1% of population 18 years and older. Previously, we were told that only those groups included in the Voting Rights Act were included in the goals and timetables for delegate selection. Yet the lesbian and gay communities were included for the first time at the 2000 convention and again at the 2004 convention Would you support a campaign to set a goal that 10% of the total New York State Delegation to the 2008 Democratic National Convention be comprised of persons with disabilities?

    

    

Candidate Signature: ___________________________________

Date: ______________________