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: RequiredNEAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code: Required County: Required Tell us about yourself Do you consider yourself? Required-- Please Select --Hard of HearingLate DeafenedDeafHearingDeaf/Low VisionOther If other, please explain: Do you have a Cochlear Implant?-- Please Select --YesNo Do you use a Hearing Aid?-- Please Select --YesNo Do you use a Personal FM System?-- Please Select --YesNo How did you hear about the program? -- Please Select --FriendHealth ClinicInternetReferred by another State AgencyTV/Radio/NewspaperOther If other, please explain: NCDHH Newsletter Would you like to receive the NCDHH newsletter? Required-- Please Select --YesNo For security purposes, please check the "I am not a robot" box below before submitting this form.