Name

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1. Name

Telephone Number

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2. Telephone Number

Briefly describe the disability of the member of your household, and how it is affecting his or her use of our services:

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3. Briefly describe the disability of the member of your household, and how it is affecting his or her use of our services:

Please check the service(s) with which your household member is experiencing difficulty due to his or her disability.

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4. Please check the service(s) with which your household member is experiencing difficulty due to his or her disability.

Are you aware of any devices or services that could help alleviate these difficulties?

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5. Are you aware of any devices or services that could help alleviate these difficulties?

May we contact you further about accessibility issues?

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6. May we contact you further about accessibility issues?

What is the best time and manner to contact you?

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7. What is the best time and manner to contact you?

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