Contact Information

Name: Select Mr. Ms. Mrs. Miss    
                         (First Name)                       (Last Name)

Address:         

               (Street Address)                              (Apt #)       (City,  State)                           (Zip)        

Home Telephone Number:     Work Telephone Number:    
                                           ###-###-####                                                     ###-###-####
Do you prefer to use a TTY/TDD (Telephone for the Deaf)?  Select YES NO

Email Address:

Please answer the following questions.

Please, select any questions that may apply to you.

1.  Have you been denied the chance  to attend college part-time, when the reason for your part-time attendance is your disability?

2.  Have you been denied VR services b/c you don't want to take medication that is traditionally recommended for your disability?

3.  Have you had difficulty accessing VR services because of language or cultural barriers?

4.  Have you had difficulty accessing VR services or received confusing information because you are also receiving welfare benefits?

5.  Have you been asked by VR to sign blank or incomplete forms?

6.  Do you have questions or concerns about VR's financial needs test (FNT) form, or its agreement to repay?

7.  Have you been found ineligible for VR services even though you receive SSI or SSDI?

8.  Do you have questions about the changes to the VR college policy?

9.  Have you requested a reasonable accommodation, or complained about disability discrimination at work, and then been fired within the same month?

10.  Have you been denied an interpreter by a Dr. or other health care provider?

11.  Have you been denied access to a Dr. or health care provider's office?

12.  Have you been denied professional liability insurance because of a disability?

13.  Have you been denied a speech, magnification or mobility device by Medicare or a private insurance company?