US Programs Survey Thank you for your interest in this initiative lead by SEE International. By completing this survey, you are indicating that you would like to know more regarding how you can become more involved with SEE’s US Programs. Question Title * 1. Full Name Question Title * 2. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Question Title * 3. Are you currently involved in providing humanitarian eye care in your community? Check all that apply. I’m participating in screenings/clinics day events I’m participating in surgical clinic day events I’m seeing patients in my practice on a case by case basis I’m volunteering at a clinic in my area on a regular schedule I am not currently volunteering, but I would like to start! Other: Question Title * 4. Do you face any barriers in which SEE can provide program support? Check all that apply. Building relationships with local clinics/organizations for referrals Consumable/Medication Procurement Logistic and/or Administrative Support Access to an OR/Surgical Center or negotiating Surgical Facility Fees Other: Question Title * 5. Has SEE supported your domestic work in the past? Yes No Question Title * 6. In what capacity would you like to participate with SEE’s US Programs? Check all that apply. Hosting or supporting a Comprehensive Eye Exam Clinic Day Hosting or supporting a Surgical Clinic Day Seeing patients on a case by case basis Other: Question Title * 7. When would you be able to participate? As soon as possible Within 3 to 6 months Within a year Other Question Title * 8. Additional Comments or Questions Please share this survey with anyone you think may be interested in getting involved. SEE International175 Cremona Drive, Suite 100, Santa Barbara, CA 93117p (805) 963-3303 | f (805) 965-3564 | info@seeintl.orgseeintl.org Submit
