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/HospitalCountyOffice

 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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