Office of Minority Health and Health Equity (OMHHE) Survey

1.Name of organization, group or individual and website if applicable:(Required.)

Entity Name:

Website:

3.Please provide at least two contacts:(Required.)

Contact 1:

Phone:

Email:

Contact 2:

Phone:

Email:

Contact 3:

Phone:

Email:

4.Organization contact information:(Required.)

Mailing or street address:

City:

Zip code:

Phone:

Email:

5.County where located(Required.)

6.Counties served(Required.)

Office of Minority Health and Health Equity (OMHHE)