PACE, Inc.

Confidential disability, age, ethnic etc. info is gathered to assure PACE is serving all types of people who have all types of disabilities. It is reported to funding sources as statistics without your identity.

PACE, Inc. Requester Information Form

Fields with a "*" are required.

Information Type*	What information are you requesting?
Name*	Legal name of person making the request
Requestor is:*
Agency
Address*
City*
State*
Zip Code
County*
Home/cell Phone (voice or tty)
Work Phone (voice or tty)
Fax
Email Address*
Date of Birth*
Age*
Race*
Origin*
Gender*
DISABILITY
Disability Status*
If so, please check disability type(s):
____________________________
Vision
Type:
Check those that apply:
Macular Degeneration
Diabetic Retin.
Glaucoma
Cataracts
Other
____________________________
Hearing
Type:
____________________________
Mental/Emotional
____________________________
Cognitive
Type:
____________________________
Physical
Type:
____________________________
Other
Type:
____________________________
Is your disability considered a Developmental Disability?
Answer:
____________________________
Additional Information	Please write any additional information you think would be useful to PACE.