* 1. My Name

* 2. My Email address

* 3. I am affiliated with (check all that apply):

* 4. Total number of Disability Policy Seminar participants in Hill meeting:

* 5. Chamber:

* 6. Member of Congress Last Name:

* 8. Interest/Involvement in disability issues:

* 9. Member of Congress:

* 10. Congressional Staff Member(s):

* 11. Staff Member(s) name(s) and title(s) (type N/A if none present):

* 12. Member's positions on our issues:

  Supports our position Does not support out position Neutral/non-commital Not discussed
Health Care
Medicaid and LTSS
Federal Funding
Social Security and SSI

* 13. Additional comments (any information you provide will help us in our advocacy):

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