Disability-Competent Care Self-Assessment Tool Survey

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* 1. First Name

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* 2. Last Name

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* 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.

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* 4. What type of organization do you represent?

Advocacy

Health Plan

Provider

Government Agency

Other (please specify)

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* 5. Please enter the name of the organization that you are affiliated with

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* 6. Please enter the state (location) where you are based