Consumer Story Bank Registration

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form if you are interested in your story being shared with the public as part of CDPAANYS' efforts to highlight the impact of COVID-19 on Consumer Directed Personal Assistance in New York.

By providing information here, you agree to be contacted by CDPAANYS and may be asked to speak to the media or interviewed.

Email *

About you

Reporters and elected officials often are looking for specific types of stories from people in specific areas. To make sure your story has as much impact as possible, we would like to know a little bit more about you. We will not share your personal information without your consent, and we never share contact information or sell our list.

I am a: *

Consumer

Designated Representative

Personal Assistant (worker)

Other:

Name *

Phone number *

E-mail address *

I prefer to be contacted by: *

Phone

In which region do you live? *

Western New York

Central New York

Capital District

Hudson Valley

Long Island/Westchester

New York City

Which category below includes your age? *

Under 18

18-64

65+

What is your gender? *

Female

Male

Non-binary

My gender identity is not listed

Other:

I identify my race or ethnicity as: *

Asian

Black or African American

Caucasian

Hispanic/Latin(x)

Native American

Pacific Islander

Other:

Required

What is your highest level of education completed:

Less than high school degree

High school degree or equivalent (e.g., GED)

Associate's (2 year) degree

Bachelor's (4 year) degree

Post-graduate degree

Clear selection

Employment *

I am employed part-time

I am employed full-time

I am seeking employment

I am unable to work

I am retired

Clear form

Never submit passwords through Google Forms.

This form was created inside of CDPAANYS. Report Abuse

Forms