National Disability Forum FY 2019

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (Fast Track)

Sample 2 - Registration Template - NDF

National Disability Forum FY 2019

OMB: 0960-0788

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National Disability Forum Registration

(i.e. State of Medicine - Biomarkers

Wednesday, July 10, 2019)


*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

  • Facebook

  • Google Plus

  • LinkedIn

  • Twitter

  • 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 Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWashington, Nikia
File Modified0000-00-00
File Created2021-01-15

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