This survey will help us to direct appropriate referrals to your agency. Please make sure to fill in the survey as completely as possible. Thank you for your cooperation!
Organization’s Legal Name:
______
AKA (if applicable):
______
Address:
______
Mailing Address (If Different):
______
Travel Instructions (Example: Two blocks south of First and Main Street, across from the Post Office):
______
Is there public transportation to this location? Yes No
Telephone:(_____) ______ext. ______
Toll-Free:(_____) ______ext. ______
FAX: (_____) ______ext. ______
TDD/TTY:(_____) ______ext. ______
Other:(_____) ______ext. ______
Hours:______
Agency Director/Title:
______
Phone: (_____) ______ext. ______
Email Address: ______
Agency Contact Person/Title:
______
Phone: (_____) ______ext. ______
Email Address: ______
General Information
Please mark the category/categories that best describes your organization.
Church Affiliated Coalition/Other Group
Private/Non-Profit Proprietary
Public – City Public – County
Public – Federal Public – State
Special District Other, as follows:______
Facility Type
Please mark the category/categories that best describes your organization.
Church Clinic/HospitalCountyOffice
School Private Practitioner Other, as follows:______
Website Address:______
General Email Address (e.g. ):______
Federal ID (EIN) #____________
Year Incorporated: ______
Accessibility:
Designated Parking Ramps
Elevators Full Wheelchair Access
Limited Access Lowered Elevator Controls
No Access No Stairs in Service Area
Not Applicable Other______
Funding Info:
Corporation Donations Fees
FEMA HUD Independent Fundraising
JTPA City Funding County Funding
Private Funding State Funding United Way Funding
Administrative Description/Mission:
______
Administrative Hours:
______
______
Program/Service Name:______
Program/Service Description: (attach additional sheet(s) as necessary):
______
Program/Service Location (Please check and list the location(s) at which this program/service if offered):
Site 1:Main/Administrative Office
Site 2:______
Site 3:______
Site 4:______
Site 5:______
Program/Service Contact Information (Name/Title):
______
Phone: (_____) ______ext. ______
Email Address: ______
Program Hours:
______
Check here if this service is not available year-round or on a consistent basis. Explanation: ______
Application: Referral Required From:______
Appointment Required
Walk-Ins
Documentation Required (Photo ID, Proof of Income or Residence, etc.):
______
Eligibility Requirements (Income, Age, Gender, Location, etc.):
______
Fees/Payment Methods (Set fees, Sliding scale, Medicaid, Medicare, etc.):
______
Languages Offered: English Other, as follows: ______
Waiting List for Service: Yes No
Form Completed By (Name/Title):
______
Phone: (_____) ______ext. ______
Email Address: ______
Date Completed: ______
Check here to be included on the 2-1-1 Community Announcement list-serv.
Has 2-1-1 expanded your knowledge of community resources?
Yes No, please explain. ______
Contact for Future Organizational Updates/Surveys, If Different (Name/Title):
______
Phone: (_____) ______ext. ______
Email Address: ______
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Thank you for taking the time to provide this information. Your responses will help us to better meet the needs of the people in our communities.
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For Administrative Use Only
Date info taken:______
Staff/Volunteer receiving info:______
Date entered into database: ______
Entered By:______
Record Number: ______
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Central Michigan 2-1-1Revised 11/2/2018
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Please send the completed form to: Questions or Comments?
Central Michigan 2-1-1 Revised 11/2/2018
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Resource Specialist
Central Michigan 2-1-1
1200 N West Ave
Jackson, MI 49202
Fax: (517) 789-1271
For Jackson, Hillsdale, Lenawee or Genesee Counties Contact:
Jessica Embury
(517) 789-1292
For Clinton, Eaton, Ingham, Livingston or Shiawassee Counties Contact:
Terrina Liogghio
(517) 789-1238
Central Michigan 2-1-1 Revised 11/2/2018
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