Demographics
Name
Phone number
Email Address
Mailing address
Business Name
Support Broker Information
Authorization number #
Date Authorized
Month
Day
Year
Do you have an employer-employee relationship with any fiscal intermediary or with OPWDD?
Are you accepting new clients?
Are you certified as a housing navigator?
Number of individuals you support?
0-24
25-49
50-74
75+
Do you support budgets with housing?
If yes, how many?
Would you be interested in being a committee member?
Would you be interested in being a mentor for Alliance members?
Fluent in a language(s) other than English? Which?
Are there additional expert competencies you wish to disclose to the Alliance?
Are you affiliated with any other self-direction, I/DD organizations, or any advocacy groups (ex. SANYS, NY Alliance for Inclusion and Innovation?
Are there any speakers or subject matter experts you would like NYISBA to feature in a future training session? If so, who?
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NYISBA Questionnaire
