MFAC Survey 2023 Complete the Survey Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Preferred Contact Method (choose one)(Required)PhoneEmailEthnicity(Required) Black or African American Asian Native Hawaiian or Other Pacific Islander White Other Choose One(Required) Hispanic or Latino Not Hispanic or Latino Preferred Language(Required) Name of person served by ACA/NY(Required) First Last Are you an ACA/NY(Required)Member/Self-AdvocateFamily MemberRepresentative/AdvocateHow long have you been involved in services for yourself/your loved one?(Required)0-55-1010-1520+ yearsWhat special interests, skills or experience have you gained or learned from your loved ones' experience?(Required)Are there topic areas you feel the CCO needs to dedicate special attention to?(Required)Are you affiliated with any other groups or organizations that could be helpful to the council?(Required)What areas do you have the most experience with?(Required) Self Direction Certified Residential Setting (IRAs) Community Habilitation Day Habilitation Housing Employment Respite Family Support Services Environmental Modifications Adaptive Technology Behavioral Health Care/Mental Health Services Complex Medical Conditions Other If other, please explain.(Required) What Sub-Committees are you interested in?(Required)Self AdvocacyFuture PlanningSelf DirectionAdvocacyOtherIf other, please explain.(Required)