National Disability Forum Registration
(i.e. Acquisition and Usage of Electronic Medical Records
Wednesday, August 22, 2018)
*1. Title
*2. First Name
3. MI
*4. Last Name
5. Suffix
*6. Phone Number
*7. Email Address
*8. Verify Email Address
*9. Name of Your Organization
*10. Organization Type
Federal Government - Social Security Administration (SSA) only
Federal Government - Others
State Government - Disability Determination Services (DDS) / Disability Adjudication Services (DAS) only State Government - Others
Local Government
Private
Nonprofit
College/University
Healthcare
Faith-based
Military
Other (please specify)
*11. Job Title
*12. How will you participate?
In-person
Livestream
*13. Do you require special accommodation?
Yes
No
If yes, please explain:
*14. How did you learn about this event?
Email from SSA
socialsecurity.gov
National Disability Forum Website
Social Security Update Newsletter
Google Plus
Blogs or Community Chats
Internet Search
Colleague
Other (please specify)
“Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions (OR participate in this focus group OR complete this telephone survey) unless we display a valid Office of Management and Budget control number. We estimate that it will take about 2 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.”
OMB Number: 0960-0788
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Washington, Nikia |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |