The purpose of this survey is to identify organizations who may have an interest in partnering with Enroll Nebraska. Enroll Nebraska is made up of organizations who have an interest in connecting consumers to the health care via the Marketplace. Please help us by telling us about your organization. This information will remain confidential and will only be used to help connect you with resources to engage your community in the Health Insurance Marketplace. Thank you!

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* 1. Organization name:

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* 2. Organization contact person:

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* 3. Organization contact information e-mail:

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* 4. Organization contact phone number:

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* 5. Our organization is best described as:

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* 6. Our organization's focus is to:

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* 7. Our organization currently organizes the following activities or has the following priorities:

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* 8. Our target population is categorized as:
(Check all that apply)

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* 9. Our organization serves the following counties in NE:

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* 10. Do you have access to the zip code for your patrons/customers?

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* 11. What is that zip code?

Resources

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* 12. Our organization performs the following hours/week of community outreach:

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* 13. Our organization can dedicate the following hours of staff time to ACA Outreach & Enrollment:

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* 14. Our organization has money budgeted/allocated to ACA for the following services:
(Check all that apply)

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* 15. Our organization has the following resources:
(Check all that apply)

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* 16. Our organization has substantive expertise in the following areas:
(i.e. grant writing, policy analysis, client outreach)

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* 17. Our organization can host a public meeting and has the following resources:
(Check all that apply)

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* 18. Please list other organizations that you think would be interested in ACA outreach and education:

Needs

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* 19. Our organization needs the following to conduct ACA outreach and enrollment:
(Check all that apply)

Outreach Plan

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* 20. Our organization plans to:
(Check all that apply)

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* 21. Our organization plans to perform the following outreach:
(Check all that apply)

Participation Interest

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* 22. Our organization is interested in participating in the following teams:
(Check all that apply)

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* 23. Our organization has staff that are interested in becoming Certified Application Counselors

T