Disability-Competent Care Self-Assessment Tool Survey
1.
First Name
2.
Last Name
3.
Please enter your email address if you would like to be added to the RIC Listserv to receive updates about new Disability-Competent Care products and webinars.
*
4.
What type of organization do you represent?
(Required.)
Advocacy
Health Plan
Provider
Government Agency
Other (please specify)
5.
Please enter the name of the organization that you are affiliated with
*
6.
Please enter the state (location) where you are based
(Required.)
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other (please specify)