Disabilities/Access and Functional Needs Partner Interest Form

Disabilities/Access and Functional Needs

Partner Interest Form

The D-AFN working group is an inclusive space for people with disabilities or access and functional needs across the state to share their pressing health concerns with DOH, get answers and influence decision-making. The workgroup is intended to center and prioritize people with disabilities and intersecting marginalized identities who experience compounded oppression. We meet via Zoom the 3rd Monday of each month from 4:30-6:00 p.m. Pacific Time. Compensation of $60/hour is available for those whose organizations are not already paying them to participate

Preferred First Name:*

Preferred Last Name:*

Pronouns (optional):

Email Address:*

My interest in the issue of disability access and functional needs is based on (check all that apply)*

I have a disability or access and functional needs

I have a family member or loved one who has a disability or access and functional needs

I serve those who are or have a disability or access and functional needs

Other

If other selected, reason below:

What kind of disability or access and functional need?

What are your goals in participating in the D-AFN Workgroup?*

Which of the following reflects your identity?

Select or enter value

Do you communicate primarily in a language other than English?*

Select

What language?*

What county do you live in?*

I am interested in joining the workgroup as:*

Select or enter value

If you selected organization or public sector agency, what is the name of your organization?*

Which geographic region does your organization serve?*

Select or enter value

Which groups does your organization serve?*

Select or enter value

Are there specific accommodations that would help support your participation in the workgroup?*

Responses to this form may be subject to public record rules.

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