Health Care Provider Access Survey

PART I: Contact Information

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Thank you for taking the time to complete the Healthcare Provider Access Survey. Providing this information will help us to gain a better understanding of the services and accessibility available to people with disabilities and their families in Delaware.

For questions, please contact Terri Hancharick, Research Associate, Center for Disabilities Studies

Phone: 302.831.8374
Email: terrih@udel.edu
Fax: 302.831.4690
Link to online survey: www.surveymonkey.com/S/2010md
Please complete and return survey no later than Friday, September 24, 2010.

Name and credentials of health care provider completing the survey:

Name of contact person in practice:

Name of practice:

Address (if your practice has multiple locations please list the main location only):

Address (if your practice has multiple locations please list the main location only): Street, Suite:
City:
State:
Zip:
Phone:
Fax:
Email:
Website: