How Black and Latinx Healthcare Workers in Support Roles Are Coping

Business Name

Services Provided

Contact Name

Contact Phone Number

Contact Email

Do you have an active business license?

Yes

No

Do you have liability/workman’s compensation insurance?

Yes

No

Do you have a Minority business certificate?

Yes

No

Do you or any officers of your business have any Criminal records – must not be excluded by the Office of Inspector General (OIG)?

Yes

No

Can you produce Business References?

Yes

No

Can you work on payment terms?

Yes

No

Do you or any officers of your business have any Criminal records or exclusions from the Office of Inspector General (OIG)?

Yes

No

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