1. In many movies, books and television shows, persons with epilepsy are portrayed as being “crazy” or evil.”	1 2 3 4 5
2. After a seizure, provincial regulatory bodies many revoke the driver’s license of a person with epilepsy.	1 2 3 4 5
3. Some people with epilepsy can’t afford their medication.	1 2 3 4 5
4. The medical community is not always properly trained about how to inform and educate people about epilepsy.	1 2 3 4 5
5. People with epilepsy are more likely to be under- or unemployed.	1 2 3 4 5
6. Police, teachers, and other public servants are often not properly trained to deal with person with epilepsy.	1 2 3 4 5
7. “Children and adults with epilepsy often experience barriers to and a lack of support for education.”	1 2 3 4 5
8. The use of strobe lights in television and video games can cause seizures in some people.	1 2 3 4 5
9. Some people with epilepsy may find it more difficult to get life insurance and health benefits.	1 2 3 4 5
10. Generic Anti-Seizure Medication is automatically substituted by the pharmacist with no requirements to inform the patient – are you concerned by this lack of disclosure?	1 2 3 4 5
11. At a Canada-wide level, whom would you like to speak on your behalf as a person living with or affected by epilepsy?	a) Canadian Epilepsy Alliance b) The Canadian Epilepsy Alliance member in your area c) Another Association (please name below)
If you answered "c) Another Association" to Question 11, please tell us who you mean.
Please indicate your top three choices from the above list and briefly tell us why the statement concerns you. EXAMPLE: The #1 Most important issue to me is Question 5. This is because it directly effects me.
Are there other issues affecting people with epilepsy that are not listed here, but where are of concern to you? If so, please describe them briefly.
Please indicate your association with epilepsy. (Please check all that apply)	Person with epilepsy Spouse of person with epilepsy Parents of child with epilepsy Physician Other (please name below)
If you answered "Other" to the above question, please tell us what you mean.
Indicate your age. (Please check one of the following)	20 years old or less 21-40 years 41-60 years 61 years old or more
The Canadian Epilepsy Alliance welcomes your comments and suggestions regarding this survey, our resources, or the organization itself. Please feel free to use this space to express your thoughts.
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