NCPAD:Personal Trainers Database

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Disability/Condition

Physical Activity

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Thank you for participating in this survey. Your feedback will help us to provide better information on the kinds of personal training services available to people with disabilities. It will also allow us to provide visitors to our Website with information about the services you provide. The results of this survey will be kept in an online database of personal trainers who work with people with disabilities.

Participation in this survey is voluntary. The survey will take approximately 10 minutes to complete. Please fill in all items to the best of your knowledge. If you have any questions regarding this survey or would like to update an excisting submission, please contact ncpad@uic.edu or call our toll-free number at 800-900-8086.

All items marked with a * are required.

Contributor information

Your Name:

Your Email:

Personal Trainer General Information

Trainer Name:

Address Line 1:

Address Line 2:

City:

State:

Zip code:

Country:

Telephone:

TTY:

Toll Free Telephone:

Fax:

URL:

Email:

General Description

Please provide a general description of your personal training services.*

How long have you been a personal trainer in months:

Where do you personal train? (check all that apply)

Fitness Center / Health Club:

Client's home:

Trainer's home:

Other public facility (park district, YMCA):

Do you have any of the following certifications?

ACSM certification (please specify which one):

ACE certification (please specify which one):

Other certification (please specify which one):

Courses

What continuing education programs, related to people with disabilities have you attended and completed in the past 5 years?

Certifying institution

Program name / Course title

Date completed (month/year)

Do you have any of the following degrees?

Occupational Therapist (OT):

Occupational Therapist Assistant:

Physical Therapist (PT):

Physical Therapist Assistant:

Registered Nurse with some coursework in exercise physiology or other related area:

Degree in Kinesiology / Physical Education / Exercise Science with some coursework in disability:

Specialization in Adapted Physical Education:

Specialization in Therapeutic Recreation:

Other, please specify:

I have trained/am currently training individuals with disabilities or health conditions who are:

Children:

Adolescents:

Young adults:

Adults:

Older adults:

Seniors ( >65 years old):

All ages:

I have trained/am currently training individuals with the following disabilities and health conditions:

AIDS:

Alzheimer:

Amputation:

Arthritis:

Autism:

Cancer:

Cardiovascular disease:

Chronic fatigue syndrome:

Hearing impairment:

Diabetes:

Emotional disturbance:

Epilepsy:

Fibromyalgia:

Frailty:

Head injury:

Intellectual disabilities:

Learning disabilities:

Low back pain:

Multiple disabilities:

Multiple sclerosis:

Muscular dystrophy:

Obesity:

Orthopedic impairment:

Osteoporosis:

Parkinson's disease:

Post-polio disease:

Pulmonary disease:

Speech or Language impairment:

Spinal cord injury:

Stroke / Brain attack:

Visual impairment:

Other, please list:

Adaptive equipment

If you currently use any adaptive equipment or assistive devices with your clients with disabilities, please list a few examples here:

Personal training fees

Do you offer any sliding/adjusted fee scales or discounts for your clients with disabilities?:

Yes
No

Transportation

Is your program/facility accessible by public transportation?:

Yes
No

Do you provide transportation to your training facilities?:

Yes, with a fee
Yes, free of cost
No transportation arrangement made

Thank you for completing this survey! Now press the button below to submit it.

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