DD Service Availability Survey
Please complete ONE per physical location.
1. Enter the agency's name.
Enter name of the entire agency, not just this location.
Your answer
2. Enter the name of this location.
Enter name of the location you are referencing in this survey (if different from agency name).
Your answer
3. Enter the name of the primary contact (Last Name, First name) at this location.
Enter the primary contact at this physical location.
Your answer
4. Enter the title of the primary contact.
Enter the title of the primary contact at this location.
Your answer
5. Enter the phone number (with area code) of the primary contact.
Enter the phone number of the primary contact at this location (e.g. xxx-xxx-xxxx)
Your answer
6. Enter the email address of the primary contact.
Enter the email address of the primary contact at this location.
Your answer
7. Enter the 5 digit ZIP Code of this location.
Your answer
8. Indicate ALL of the services offered at this location prior to the start of the amended DD Waivers.
Check all that apply.
9. Indicate the cities/counties where this location currently provides services.
Check ALL that apply.
10. Enter the number of individuals currently supported at this location. *
Enter only the number.
Your answer
11. Enter the the number of individuals that can be supported at this location. *
Enter only the number.
Your answer
12. Indicate ALL of the services this location plans to provide under Virginia's amended DD Waivers. *
Check all that apply at this location.
Required
13. Enter the date anticipated to begin offering the services indicated in item 12. *
MM
/
DD
/
YYYY
14. Is the date listed above in item 13 an estimated date? *
15. Is the program willing to expand services? *
Select one
16. List any specialized services or supports provided at this location. *
Please list any specialized supports provided.
Your answer
17. Name of person completing survey
Enter your name.
Your answer
18. Title of person completing survey.
Enter your title.
Your answer
Are you completing the survey today to update a previous submission?
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