Please complete the following survey with your success stories related to addressing financial toxicity and/or health literacy in your patient population. 

The same program may submit multiple entries. Please submit a new survey for each success story you wish to share.

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* 1. Name

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* 2. Email

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* 3. Accredited Program Name

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* 4. Facility ID Number (FIN) or Company ID:

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* 5. My success story relates to

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* 6. Describe the problem your program faced

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* 7. What resources were utilized to address the problem?

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* 8. What lessons were learned as you implemented your solution?

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* 9. Did you utilize this effort for CoC Standard Compliance?

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* 10. If you answered yes to Question 9, for which standard was this effort utilized?

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* 11. Any other information you would like to share about your above experience?

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* 12. I am authorized to give consent on behalf of my program to share this experience publicly.

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