The Nebraska Commission for the Deaf and Hard of Hearing (NCDHH) is conducting a voluntary registry of all the deaf and hard of hearing residents in Nebraska. Knowing the number of deaf and hard of hearing people in Nebraska helps NCDHH plan for needed services. If you are deaf or hard of hearing, please fill out this form. Registry Submit Form Please submit a new form for each person who is at the same address. Section 71.4728(5) of the Revised Statutes of Nebraska requires the Nebraska Commission for the Deaf and Hard of Hearing (NCDHH) to conduct and maintain a voluntary census of Nebraska citizens who have a hearing loss. All information provided to the Commission on this form will be held strictly confidential. Registering with NCDHH: Helps NCDHH make better planning decisions Helps NCDHH improve services First Name: Required Last Name: Required Business Name: Email Address: Required Phone Number: Required Year of Birth: Required Address: Required City: Required State: Required NE AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code: Required County: Required Tell us about yourself Do you consider yourself? Required -- Please Select -- Hard of Hearing Late Deafened Deaf Hearing Deaf/Low Vision Other If other, please explain: Do you have a Cochlear Implant? -- Please Select -- Yes No Do you use a Hearing Aid? -- Please Select -- Yes No Do you use a Personal FM System? -- Please Select -- Yes No How did you hear about the program? -- Please Select -- Friend Health Clinic Internet Referred by another State Agency TV/Radio/Newspaper Other If other, please explain: NCDHH Newsletter Would you like to receive the NCDHH newsletter? Required -- Please Select -- Yes No For security purposes, please check the "I am not a robot" box below before submitting this form.