Submit a Tool: Improving the Receipt
of Clinical Preventive Services among Women with Disabilities

Thank you for submitting a request to include a potential resource for the online Toolbox: Improving the Receipt of Clinical Preventive Services among Women with Disabilities. Please complete the form below to the best of your knowledge and AMCHP staff will follow-up on your request.

Click "Submit" when you are done to send us your referral.

Question Title

* 1. Name of tool:

Question Title

* 2. Brief description (i.e. Format, content, what tool is used to accomplish, etc.):

Question Title

* 3. Audience (who uses the tool):

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* 4. Available from (URL):

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* 5. Does the tool have any of the following attributes? (Check all that apply)

Readily available online

Designed to facilitate the receipt or provision of clinical preventive services applicable to or specifically targeted to women with disabilities

Interactive or hands-on

User-friendly or requiring minimal training

Useful to clinicians, communities and public health service programs, and educators who interact with practitioners and women with disabilities, and women with disabilities as applicable.

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* 6. Contact information for the tool:

Contact Name:

Phone:

Email:

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* 7. Your (referrer's) contact information (optional):

Name:

Organization:

Phone:

Email:

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* 8. When contacting staff about the tool, can we mention that you referred them for inclusion in the toolbox?

Yes

Other (please specify)

Question Title

* 1. Name of tool:

Question Title

* 2. Brief description (i.e. Format, content, what tool is used to accomplish, etc.):

Question Title

* 3. Audience (who uses the tool):

Question Title

* 4. Available from (URL):

Question Title

* 5. Does the tool have any of the following attributes? (Check all that apply)

Question Title

* 6. Contact information for the tool:

Question Title

* 7. Your (referrer's) contact information (optional):

Question Title

* 8. When contacting staff about the tool, can we mention that you referred them for inclusion in the toolbox?

Question Title

* 9. Additional comments: