US Programs Survey

Thank you for your interest in this initiative lead by SEE International. By completing this survey, you are indicating that you would like to know more regarding how you can become more involved with SEE’s US Programs.

1.Full Name(Required.)

2.State(Required.)

3.Are you currently involved in providing humanitarian eye care in your community? Check all that apply.

I’m participating in screenings/clinics day events

I’m participating in surgical clinic day events

I’m seeing patients in my practice on a case by case basis

I’m volunteering at a clinic in my area on a regular schedule

I am not currently volunteering, but I would like to start!

Other:

4.Do you face any barriers in which SEE can provide program support? Check all that apply.

Building relationships with local clinics/organizations for referrals

Consumable/Medication Procurement

Logistic and/or Administrative Support

Access to an OR/Surgical Center or negotiating Surgical Facility Fees

Other:

5.Has SEE supported your domestic work in the past?

Yes

No

6.In what capacity would you like to participate with SEE’s US Programs? Check all that apply.

Hosting or supporting a Comprehensive Eye Exam Clinic Day

Hosting or supporting a Surgical Clinic Day

Seeing patients on a case by case basis

Other:

7.When would you be able to participate?

As soon as possible

Within 3 to 6 months

Within a year

Other

8.Additional Comments or Questions

Please share this survey with anyone you think may be interested in getting involved.

SEE International
175 Cremona Drive, Suite 100, Santa Barbara, CA 93117
p (805) 963-3303 | f (805) 965-3564 | info@seeintl.org

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