My Name

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* 1. My Name

My Email address

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* 2. My Email address

I am affiliated with (check all that apply):

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

Total number of Disability Policy Seminar participants in Hill meeting:

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

Chamber:

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* 5. Chamber:

Member of Congress Last Name:

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* 6. Member of Congress Last Name:

Interest/Involvement in disability issues:

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* 8. Interest/Involvement in disability issues:

Member of Congress:

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* 9. Member of Congress:

Congressional Staff Member(s):

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* 10. Congressional Staff Member(s):

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

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

Member's positions on our issues:

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

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

If you have additional meetings to report, please complete this survey and then click on the original link to begin another one.

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