National Disability Forum FY 2019

National Disability Forum Registration

(i.e. State of Medicine - Biomarkers

Wednesday, July 10, 2019)

*1. Title

*2. First Name

3. MI

*4. Last Name

5. Suffix

*6. Phone Number

*7. Email Address

*8. Verify Email Address

*9. Name of Your Organization

*10. Organization Type

• Federal Government - Social Security Administration (SSA) only

• Federal Government - Others

• State Government - Disability Determination Services (DDS) / Disability Adjudication Services (DAS) only State Government - Others

• Local Government

• Private

• Nonprofit

• College/University

• Healthcare

• Faith-based

• Military

• Other (please specify)

*11. Job Title

*12. How will you participate?

• In-person

• Livestream

*13. Do you require special accommodation?

• Yes

• No

If yes, please explain:

*14. How did you learn about this event?

• Email from SSA

• socialsecurity.gov

• National Disability Forum Website

• Social Security Update Newsletter

• Facebook

• Google Plus

• LinkedIn

• Twitter

• Blogs or Community Chats

• Internet Search

• Colleague

• Other (please specify)

“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 answer these questions (OR participate in this focus group OR complete this telephone survey) unless we display a valid Office of Management and Budget control number. We estimate that it will take about 2 minutes to read the instructions, gather the facts, and answer the questions. 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.”

OMB Number: 0960-0788