Disability Awareness Survey

Approved, OMB Number 0960-0788

Information Sheet for “Many Faces of Disability” Disability Awareness Campaign

Thank you for sharing your story with us for the “Many Faces of Disability” disability awareness campaign. Your story will help us communicate to the public the importance and benefits of disability programs and the positive affect that the programs have on individuals and their families.

Participant’s Name___________________________________

“Feel Good” Story - (Please briefly explain your story - why you feel Social Security Disability is important and how it impacts your life.)

Name of Organization___________________________________

Organization Contact’s Name___________________________

Contact Phone Number________________________________

Paperwork Reduction Act Statement

This information collection meets the requirements of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to complete this form unless we display a valid Office of Management and Budget control number. We estimate that it will take about 30 minutes to read the instructions and write your story. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.