Please complete this survey and submit. This is a secure form.

Your feedback will help us advocate in Washington, D.C. to change policies that affect your mobility and independence.

* 1. Your name:

* 2. We would like to follow up with you if we have any questions. Please provide email address or phone number.

* 3. Can we share your information with elected officials?
Making elected officials aware of disability issues helps us obtain their support for our issues.

* 4. What insurance coverage do you have?

* 5. What durable medical equipment (DME) do you use?

* 6. Have you had difficulty contacting a supplier of DME?

* 7. Have you had to wait for the DME supplier for service?

* 8. Have you had incorrect repairs or wrong supplies from your DME?

* 9. Have you lost your supplier within the last 3.5 years?

* 10. Do you understand what competitive bidding is?

* 11. How long have you used a wheelchair or other medical equipment/supplies?

* 12. What is your age?

* 13. Please enter your 5-digit ZIP code (for example, 00544 or 94305). We would like to know exact locations of access problems so that we can share with the right elected officials.

* 14. Any additional comments?

Thank you for your time in filling out this survey. This information helps us describe to policymakers the problems wheelchair users are having due to the competitive program regarding accessing needed medical equipment, supplies and service.