Consumer Directed Personal Assistance Issue Reporting Form

Name of person reporting issue*

First Last

Name of CDPAS consumer( If different from person reporting issue)

First Last

Report An Issue*

Please briefly provide a summary of your issue.

CDR employee(s) you have spoken to regarding issue (if applicable)

Your email (please provide your email that you use to communicate with CDR)*

Additional Email (if you have different emails that you used in communication)

Your Phone (please provide your phone number that you use to call CDR)*

Additional Phone (if used)

Requested Resolution

Please briefly describe the resolution you are looking for from CDR.

Ticket # in reference to this issue

(If you were provided one)

Center for Disability Rights