cookcountyhealth.org
Open in
urlscan Pro
159.140.7.107
Public Scan
Submitted URL: https://www.cookcountyhealth.org/
Effective URL: https://cookcountyhealth.org/
Submission: On May 19 via manual from US — Scanned from DE
Effective URL: https://cookcountyhealth.org/
Submission: On May 19 via manual from US — Scanned from DE
Form analysis 5 forms found in the DOM
GET https://cookcountyhealth.org/
<form role="search" method="get" class="hestia-search-in-nav form-group" action="https://cookcountyhealth.org/">
<div class="hestia-nav-search">
<span class="screen-reader-text">Search for:</span>
<span class="search-field-wrapper form-group">
<input type="search" class="search-field form-control" placeholder="Search …" value="" name="s">
</span>
<span class="search-submit-wrapper">
<button type="submit" class="search-submit hestia-search-submit"><i class="fa fa-search"></i></button>
</span>
</div>
</form>GET https://cookcountyhealth.org/
<form role="search" method="get" id="searchform" class="home_search_form form-group" action="https://cookcountyhealth.org/">
<div class="row form-group">
<span>Search by:</span>
<input type="text" class="column form-control" id="s_general" placeholder="Doctor, Symptoms, Services, Speciality...">
<input type="text" class="column form-control" id="zipCode" placeholder="Zip Code">
<input type="hidden" name="s" id="s_searchform" value="">
<button type="submit" class="btn btn-primary">SEARCH</button>
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_29" action="/" class="form-group">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform_body gform-body">
<ul id="gform_fields_29" class="gform_fields top_label form_sublabel_below description_above">
<li id="field_29_3" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Name<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_29_3">
<span id="input_29_3_3_container" class="name_first form-group">
<input type="text" name="input_3.3" id="input_29_3_3" value="" aria-required="true" class="form-control">
<label for="input_29_3_3">First Name</label>
</span>
<span id="input_29_3_6_container" class="name_last form-group">
<input type="text" name="input_3.6" id="input_29_3_6" value="" aria-required="true" class="form-control">
<label for="input_29_3_6">Last Name</label>
</span>
</div>
</li>
<li id="field_29_14" class="gfield gf_left_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_29_14">Title</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_14" id="input_29_14" type="text" value="" class="medium form-control" aria-invalid="false"> </div>
</li>
<li id="field_29_12" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_29_12">Organization</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_12" id="input_29_12" type="text" value="" class="medium form-control" aria-invalid="false"> </div>
</li>
<li id="field_29_6" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_29_6">Email<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email form-group">
<input name="input_6" id="input_29_6" type="text" value="" class="medium form-control" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_29_16" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_29_16">Mobile Phone</label>
<div class="ginput_container ginput_container_phone form-group"><input name="input_16" id="input_29_16" type="text" value="" class="medium form-control" aria-invalid="false"></div>
</li>
<li id="field_29_4" class="gfield gf_left_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_29_4">Work Phone</label>
<div class="ginput_container ginput_container_phone form-group"><input name="input_4" id="input_29_4" type="text" value="" class="medium form-control" aria-invalid="false"></div>
</li>
<li id="field_29_15" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_29_15">Work Fax</label>
<div class="ginput_container ginput_container_phone form-group"><input name="input_15" id="input_29_15" type="text" value="" class="medium form-control" aria-invalid="false"></div>
</li>
<li id="field_29_18" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_29_18">Website</label>
<div class="ginput_container ginput_container_website form-group">
<input name="input_18" id="input_29_18" type="text" value="" class="large form-control" placeholder="https://" aria-invalid="false">
</div>
</li>
<li id="field_29_7" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Address<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address" id="input_29_7">
<span class="ginput_full address_line_1 ginput_address_line_1 form-group" id="input_29_7_1_container">
<input type="text" name="input_7.1" id="input_29_7_1" value="" aria-required="true" class="form-control">
<label for="input_29_7_1" id="input_29_7_1_label">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2 form-group" id="input_29_7_2_container">
<input type="text" name="input_7.2" id="input_29_7_2" value="" aria-required="false" class="form-control">
<label for="input_29_7_2" id="input_29_7_2_label">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city form-group" id="input_29_7_3_container">
<input type="text" name="input_7.3" id="input_29_7_3" value="" aria-required="true" class="form-control">
<label for="input_29_7_3" id="input_29_7_3_label">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_29_7_4_container">
<select name="input_7.4" id="input_29_7_4" aria-required="true">
<option value=""></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois" selected="selected">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
<label for="input_29_7_4" id="input_29_7_4_label">State</label>
</span><span class="ginput_left address_zip ginput_address_zip form-group" id="input_29_7_5_container">
<input type="text" name="input_7.5" id="input_29_7_5" value="" aria-required="true" class="form-control">
<label for="input_29_7_5" id="input_29_7_5_label">ZIP Code</label>
</span><input type="hidden" class="gform_hidden" name="input_7.6" id="input_29_7_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_29_20" class="gfield field_sublabel_below field_description_above hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_29_20">CAPTCHA</label>
<div id="input_29_20" class="ginput_container ginput_recaptcha gform-initialized" data-sitekey="6Lf0r70ZAAAAAF6d7novBTVWZLCp_f4pQuqI3U5b" data-theme="light" data-tabindex="-1" data-size="invisible" data-badge="inline">
<div class="grecaptcha-badge" data-style="inline" style="width: 256px; height: 60px; box-shadow: gray 0px 0px 5px;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Lf0r70ZAAAAAF6d7novBTVWZLCp_f4pQuqI3U5b&co=aHR0cHM6Ly9jb29rY291bnR5aGVhbHRoLm9yZzo0NDM.&hl=en&v=0aeEuuJmrVqDrEL39Fsg5-UJ&theme=light&size=invisible&badge=inline&cb=tj0w3hprmu4"
width="256" height="60" role="presentation" name="a-vjdxbqvgsvgk" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"
tabindex="-1"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div>
</div>
</li>
<li id="field_29_21" class="gfield gform_validation_container field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_29_21">Name</label>
<div class="gfield_description" id="gfield_description_29_21">This field is for validation purposes and should be left unchanged.</div>
<div class="ginput_container form-group"><input name="input_21" id="input_29_21" type="text" value="" class="form-control"></div>
</li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_29" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_29"]){return false;} window["gf_submitting_29"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_29"]){return false;} window["gf_submitting_29"]=true; jQuery("#gform_29").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_29" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="29">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_29" value="WyJbXSIsIjdlY2FiOThmMTViNDgwM2YyMzE2NmUzMjg1ODZiNzJiIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_29" id="gform_target_page_number_29" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_29" id="gform_source_page_number_29" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<input type="hidden" name="pum_form_popup_id" value="131992">
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_30" class="program-participate-form gform_legacy_markup form-group" action="/">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform_body gform-body">
<ul id="gform_fields_30" class="gform_fields top_label form_sublabel_below description_above">
<li id="field_30_3" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Name<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_30_3">
<span id="input_30_3_3_container" class="name_first form-group">
<input type="text" name="input_3.3" id="input_30_3_3" value="" aria-required="true" class="form-control">
<label for="input_30_3_3">First Name</label>
</span>
<span id="input_30_3_6_container" class="name_last form-group">
<input type="text" name="input_3.6" id="input_30_3_6" value="" aria-required="true" class="form-control">
<label for="input_30_3_6">Last Name</label>
</span>
</div>
</li>
<li id="field_30_14" class="gfield gf_left_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_14">Title</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_14" id="input_30_14" type="text" value="" class="medium form-control" aria-invalid="false"> </div>
</li>
<li id="field_30_12" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_12">Organization</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_12" id="input_30_12" type="text" value="" class="medium form-control" aria-invalid="false"> </div>
</li>
<li id="field_30_6" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_6">Email<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email form-group">
<input name="input_6" id="input_30_6" type="text" value="" class="medium form-control" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_30_16" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_16">Mobile Phone</label>
<div class="ginput_container ginput_container_phone form-group"><input name="input_16" id="input_30_16" type="text" value="" class="medium form-control" aria-invalid="false"></div>
</li>
<li id="field_30_4" class="gfield gf_left_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_4">Work Phone</label>
<div class="ginput_container ginput_container_phone form-group"><input name="input_4" id="input_30_4" type="text" value="" class="medium form-control" aria-invalid="false"></div>
</li>
<li id="field_30_15" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_15">Work Fax</label>
<div class="ginput_container ginput_container_phone form-group"><input name="input_15" id="input_30_15" type="text" value="" class="medium form-control" aria-invalid="false"></div>
</li>
<li id="field_30_18" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_18">Website</label>
<div class="ginput_container ginput_container_website form-group">
<input name="input_18" id="input_30_18" type="text" value="" class="large form-control" placeholder="https://" aria-invalid="false">
</div>
</li>
<li id="field_30_7" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Address<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address" id="input_30_7">
<span class="ginput_full address_line_1 ginput_address_line_1 form-group" id="input_30_7_1_container">
<input type="text" name="input_7.1" id="input_30_7_1" value="" aria-required="true" class="form-control">
<label for="input_30_7_1" id="input_30_7_1_label">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2 form-group" id="input_30_7_2_container">
<input type="text" name="input_7.2" id="input_30_7_2" value="" aria-required="false" class="form-control">
<label for="input_30_7_2" id="input_30_7_2_label">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city form-group" id="input_30_7_3_container">
<input type="text" name="input_7.3" id="input_30_7_3" value="" aria-required="true" class="form-control">
<label for="input_30_7_3" id="input_30_7_3_label">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_30_7_4_container">
<select name="input_7.4" id="input_30_7_4" aria-required="true">
<option value=""></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois" selected="selected">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
<label for="input_30_7_4" id="input_30_7_4_label">State</label>
</span><span class="ginput_left address_zip ginput_address_zip form-group" id="input_30_7_5_container">
<input type="text" name="input_7.5" id="input_30_7_5" value="" aria-required="true" class="form-control">
<label for="input_30_7_5" id="input_30_7_5_label">ZIP Code</label>
</span><input type="hidden" class="gform_hidden" name="input_7.6" id="input_30_7_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_30_19" class="gfield gsection field_sublabel_below field_description_above gfield_visibility_visible">
<h2 class="gsection_title"></h2>
</li>
<li id="field_30_20" class="gfield gf_left_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_20">Event Name</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_20" id="input_30_20" type="text" value="" class="large form-control" aria-invalid="false"> </div>
</li>
<li id="field_30_22" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_22">Date<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_date form-group">
<input name="input_22" id="input_30_22" type="text" value="" class="datepicker mdy datepicker_no_icon gdatepicker-no-icon form-control hasDatepicker initialized" placeholder="mm/dd/yyyy" aria-describedby="input_30_22_date_format"
aria-invalid="false" aria-required="true">
<span id="input_30_22_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_30_22" class="gform_hidden" value="https://cookcountyhealth.org/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</li>
<li id="field_30_23" class="gfield gf_left_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Start Time</label>
<div class="ginput_complex">
<div class="clear-multi">
<div class="gfield_time_hour ginput_container ginput_container_time form-group" id="input_30_23">
<input type="text" maxlength="2" name="input_23[]" id="input_30_23_1" value="" placeholder="HH" aria-required="false" class="form-control"> <i>:</i>
<label class="hour_label screen-reader-text" for="input_30_23_1">Hours</label>
</div>
<div class="gfield_time_minute ginput_container ginput_container_time form-group">
<input type="text" maxlength="2" name="input_23[]" id="input_30_23_2" value="" placeholder="MM" aria-required="false" class="form-control">
<label class="minute_label screen-reader-text" for="input_30_23_2">Minutes</label>
</div>
<div class="gfield_time_ampm ginput_container ginput_container_time below">
<select name="input_23[]" id="input_30_23_3">
<option value="am">AM</option>
<option value="pm">PM</option>
</select>
</div>
</div>
</div>
</li>
<li id="field_30_24" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">End Time</label>
<div class="ginput_complex">
<div class="clear-multi">
<div class="gfield_time_hour ginput_container ginput_container_time form-group" id="input_30_24">
<input type="text" maxlength="2" name="input_24[]" id="input_30_24_1" value="" placeholder="HH" aria-required="false" class="form-control"> <i>:</i>
<label class="hour_label screen-reader-text" for="input_30_24_1">Hours</label>
</div>
<div class="gfield_time_minute ginput_container ginput_container_time form-group">
<input type="text" maxlength="2" name="input_24[]" id="input_30_24_2" value="" placeholder="MM" aria-required="false" class="form-control">
<label class="minute_label screen-reader-text" for="input_30_24_2">Minutes</label>
</div>
<div class="gfield_time_ampm ginput_container ginput_container_time below">
<select name="input_24[]" id="input_30_24_3">
<option value="am">AM</option>
<option value="pm">PM</option>
</select>
</div>
</div>
</div>
</li>
<li id="field_30_21" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label">Format<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_30_21">
<li class="gchoice gchoice_30_21_0">
<input name="input_21" type="radio" value="Work Shop" id="choice_30_21_0">
<label for="choice_30_21_0" id="label_30_21_0">Work Shop</label>
</li>
<li class="gchoice gchoice_30_21_1">
<input name="input_21" type="radio" value="Town Hall" id="choice_30_21_1">
<label for="choice_30_21_1" id="label_30_21_1">Town Hall</label>
</li>
<li class="gchoice gchoice_30_21_2">
<input name="input_21" type="radio" value="Video" id="choice_30_21_2">
<label for="choice_30_21_2" id="label_30_21_2">Video</label>
</li>
<li class="gchoice gchoice_30_21_3 form-group">
<input name="input_21" type="radio" value="gf_other_choice" id="choice_30_21_3" onfocus="jQuery(this).next('input').focus();">
<input class="small form-control" id="input_30_21_other" name="input_21_other" type="text" value="Other" aria-label="Other"
onfocus="jQuery(this).prev("input")[0].click(); if(jQuery(this).val() == "Other") { jQuery(this).val(""); }"
onblur="if(jQuery(this).val().replace(" ", "") == "") { jQuery(this).val("Other"); }">
</li>
</ul>
</div>
</li>
<li id="field_30_26" class="gfield gsection field_sublabel_below field_description_above gfield_visibility_visible">
<h2 class="gsection_title"></h2>
</li>
<li id="field_30_25" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_25">Type of Audience</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_25" id="input_30_25" type="text" value="" class="large form-control" aria-invalid="false"> </div>
</li>
<li id="field_30_27" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_27">How many participants are anticipated?</label>
<div class="ginput_container ginput_container_number form-group"><input name="input_27" id="input_30_27" type="text" value="" class="large form-control" aria-invalid="false"></div>
</li>
<li id="field_30_29" class="gfield gf_left_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label">Is the event open to the public?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_30_29">
<li class="gchoice gchoice_30_29_0">
<input name="input_29" type="radio" value="Yes" id="choice_30_29_0">
<label for="choice_30_29_0" id="label_30_29_0">Yes</label>
</li>
<li class="gchoice gchoice_30_29_1">
<input name="input_29" type="radio" value="No" id="choice_30_29_1">
<label for="choice_30_29_1" id="label_30_29_1">No</label>
</li>
</ul>
</div>
</li>
<li id="field_30_30" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label">Is a language Interpretation Needed?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_30_30">
<li class="gchoice gchoice_30_30_0">
<input name="input_30" type="radio" value="Yes" id="choice_30_30_0">
<label for="choice_30_30_0" id="label_30_30_0">Yes</label>
</li>
<li class="gchoice gchoice_30_30_1">
<input name="input_30" type="radio" value="No" id="choice_30_30_1">
<label for="choice_30_30_1" id="label_30_30_1">No</label>
</li>
</ul>
</div>
</li>
<li id="field_30_33" class="gfield gf_right_half field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label">Can we publicize the event?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_30_33">
<li class="gchoice gchoice_30_33_0">
<input name="input_33" type="radio" value="Yes" id="choice_30_33_0">
<label for="choice_30_33_0" id="label_30_33_0">Yes</label>
</li>
<li class="gchoice gchoice_30_33_1">
<input name="input_33" type="radio" value="No" id="choice_30_33_1">
<label for="choice_30_33_1" id="label_30_33_1">No</label>
</li>
</ul>
</div>
</li>
<li id="field_30_32" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_32">Virtual Platform for event:</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_32" id="input_30_32" type="text" value="" class="large form-control" aria-invalid="false"> </div>
</li>
<li id="field_30_34" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_34">What are the different social media handles for the event?</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_34" id="input_30_34" type="text" value="" class="large form-control" aria-invalid="false"> </div>
</li>
<li id="field_30_35" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_35">Tell us additional information about the event:</label>
<div class="ginput_container ginput_container_textarea form-group"><textarea name="input_35" id="input_30_35" class="textarea large form-control" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
<li id="field_30_36" class="gfield field_sublabel_below field_description_above hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_30_36">CAPTCHA</label>
<div id="input_30_36" class="ginput_container ginput_recaptcha gform-initialized" data-sitekey="6Lf0r70ZAAAAAF6d7novBTVWZLCp_f4pQuqI3U5b" data-theme="light" data-tabindex="-1" data-size="invisible" data-badge="inline">
<div class="grecaptcha-badge" data-style="inline" style="width: 256px; height: 60px; box-shadow: gray 0px 0px 5px;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Lf0r70ZAAAAAF6d7novBTVWZLCp_f4pQuqI3U5b&co=aHR0cHM6Ly9jb29rY291bnR5aGVhbHRoLm9yZzo0NDM.&hl=en&v=0aeEuuJmrVqDrEL39Fsg5-UJ&theme=light&size=invisible&badge=inline&cb=ovjzu8pymh8o"
width="256" height="60" role="presentation" name="a-qa4pl0gua4ud" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"
tabindex="-1"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response-1" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div>
</div>
</li>
<li id="field_30_37" class="gfield gform_validation_container field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_30_37">Phone</label>
<div class="gfield_description" id="gfield_description_30_37">This field is for validation purposes and should be left unchanged.</div>
<div class="ginput_container form-group"><input name="input_37" id="input_30_37" type="text" value="" class="form-control"></div>
</li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_30" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_30"]){return false;} window["gf_submitting_30"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_30"]){return false;} window["gf_submitting_30"]=true; jQuery("#gform_30").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_30" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="30">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_30" value="WyJbXSIsIjdlY2FiOThmMTViNDgwM2YyMzE2NmUzMjg1ODZiNzJiIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_30" id="gform_target_page_number_30" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_30" id="gform_source_page_number_30" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<input type="hidden" name="pum_form_popup_id" value="131989">
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_31" action="/" class="form-group">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform_body gform-body">
<ul id="gform_fields_31" class="gform_fields top_label form_sublabel_below description_above">
<li id="field_31_3" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Name<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_31_3">
<span id="input_31_3_3_container" class="name_first form-group">
<input type="text" name="input_3.3" id="input_31_3_3" value="" aria-required="true" class="form-control">
<label for="input_31_3_3">First Name</label>
</span>
<span id="input_31_3_6_container" class="name_last form-group">
<input type="text" name="input_3.6" id="input_31_3_6" value="" aria-required="true" class="form-control">
<label for="input_31_3_6">Last Name</label>
</span>
</div>
</li>
<li id="field_31_35" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Address<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address" id="input_31_35">
<span class="ginput_full address_line_1 ginput_address_line_1 form-group" id="input_31_35_1_container">
<input type="text" name="input_35.1" id="input_31_35_1" value="" aria-required="true" class="form-control">
<label for="input_31_35_1" id="input_31_35_1_label">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2 form-group" id="input_31_35_2_container">
<input type="text" name="input_35.2" id="input_31_35_2" value="" aria-required="false" class="form-control">
<label for="input_31_35_2" id="input_31_35_2_label">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city form-group" id="input_31_35_3_container">
<input type="text" name="input_35.3" id="input_31_35_3" value="" aria-required="true" class="form-control">
<label for="input_31_35_3" id="input_31_35_3_label">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_31_35_4_container">
<select name="input_35.4" id="input_31_35_4" aria-required="true">
<option value=""></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois" selected="selected">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
<label for="input_31_35_4" id="input_31_35_4_label">State</label>
</span><span class="ginput_left address_zip ginput_address_zip form-group" id="input_31_35_5_container">
<input type="text" name="input_35.5" id="input_31_35_5" value="" aria-required="true" class="form-control">
<label for="input_31_35_5" id="input_31_35_5_label">ZIP Code</label>
</span><input type="hidden" class="gform_hidden" name="input_35.6" id="input_31_35_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_31_48" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_48">Home phone</label>
<div class="ginput_container ginput_container_phone form-group"><input name="input_48" id="input_31_48" type="text" value="" class="medium form-control" aria-invalid="false"></div>
</li>
<li id="field_31_49" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_49">Cell phone</label>
<div class="ginput_container ginput_container_phone form-group"><input name="input_49" id="input_31_49" type="text" value="" class="medium form-control" aria-invalid="false"></div>
</li>
<li id="field_31_14" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_14">Email address<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text form-group"><input name="input_14" id="input_31_14" type="text" value="" class="medium form-control" aria-required="true" aria-invalid="false"> </div>
</li>
<li id="field_31_50" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_50">Preferred contact (choose one):<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_multiselect"><select multiple="multiple" size="7" name="input_50[]" id="input_31_50" class="medium gfield_select" aria-invalid="false" aria-required="true">
<option value="Home phone">Home phone</option>
<option value="Cell phone">Cell phone</option>
<option value="Email">Email</option>
</select></div>
</li>
<li id="field_31_22" class="gfield gsection field_sublabel_below field_description_above gfield_visibility_visible">
<h2 class="gsection_title">The following questions will help us get to know you better.</h2>
</li>
<li id="field_31_23" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Are you a...<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_31_23">
<li class="gchoice gchoice_31_23_1">
<input class="gfield-choice-input" name="input_23.1" type="checkbox" value="Patient" id="choice_31_23_1">
<label for="choice_31_23_1" id="label_31_23_1">Patient</label>
</li>
<li class="gchoice gchoice_31_23_2">
<input class="gfield-choice-input" name="input_23.2" type="checkbox" value="Caregiver or family member of a patient" id="choice_31_23_2">
<label for="choice_31_23_2" id="label_31_23_2">Caregiver or family member of a patient</label>
</li>
<li class="gchoice gchoice_31_23_3">
<input class="gfield-choice-input" name="input_23.3" type="checkbox" value="Local community leader" id="choice_31_23_3">
<label for="choice_31_23_3" id="label_31_23_3">Local community leader</label>
</li>
<li class="gchoice gchoice_31_23_4">
<input class="gfield-choice-input" name="input_23.4" type="checkbox" value="Representative of a religious organization" id="choice_31_23_4">
<label for="choice_31_23_4" id="label_31_23_4">Representative of a religious organization</label>
</li>
<li class="gchoice gchoice_31_23_5">
<input class="gfield-choice-input" name="input_23.5" type="checkbox" value="Staff member of a community development organization" id="choice_31_23_5">
<label for="choice_31_23_5" id="label_31_23_5">Staff member of a community development organization</label>
</li>
<li class="gchoice gchoice_31_23_6">
<input class="gfield-choice-input" name="input_23.6" type="checkbox" value="Healthcare professional" id="choice_31_23_6">
<label for="choice_31_23_6" id="label_31_23_6">Healthcare professional</label>
</li>
</ul>
</div>
</li>
<li id="field_31_24" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">If a patient or family member, when was your care experience at this Clinic?
(Check all that apply).</label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_31_24">
<li class="gchoice gchoice_31_24_1">
<input class="gfield-choice-input" name="input_24.1" type="checkbox" value="2020 to current year" id="choice_31_24_1">
<label for="choice_31_24_1" id="label_31_24_1">2020 to current year</label>
</li>
<li class="gchoice gchoice_31_24_2">
<input class="gfield-choice-input" name="input_24.2" type="checkbox" value="2019" id="choice_31_24_2">
<label for="choice_31_24_2" id="label_31_24_2">2019</label>
</li>
<li class="gchoice gchoice_31_24_3">
<input class="gfield-choice-input" name="input_24.3" type="checkbox" value="2018" id="choice_31_24_3">
<label for="choice_31_24_3" id="label_31_24_3">2018</label>
</li>
<li class="gchoice gchoice_31_24_4">
<input class="gfield-choice-input" name="input_24.4" type="checkbox" value="2017 or before" id="choice_31_24_4">
<label for="choice_31_24_4" id="label_31_24_4">2017 or before</label>
</li>
</ul>
</div>
</li>
<li id="field_31_12" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_12">What language(s) do you speak?<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text form-group"><input name="input_12" id="input_31_12" type="text" value="" class="medium form-control" aria-required="true" aria-invalid="false"> </div>
</li>
<li id="field_31_28" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_28">We recognize that our community advisors have busy lives. How much
time are you able to commit? (Check one)<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_multiselect"><select multiple="multiple" size="7" name="input_28[]" id="input_31_28" class="medium gfield_select" aria-invalid="false" aria-required="true">
<option value="1 to 2 hours per month">1 to 2 hours per month</option>
<option value="3 to 4 hours per month">3 to 4 hours per month</option>
<option value="More than 4 hours per month">More than 4 hours per month</option>
</select></div>
</li>
<li id="field_31_27" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_27">Are you available to serve as an advisor for at least 3
years?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="gfield_description" id="gfield_description_31_27">You can still support the Advisory Council if you answer "no."</div>
<div class="ginput_container ginput_container_multiselect"><select multiple="multiple" size="7" name="input_27[]" id="input_31_27" class="medium gfield_select" aria-invalid="false" aria-required="true"
aria-describedby="gfield_description_31_27">
<option value="Yes" selected="selected">Yes</option>
<option value="No">No</option>
</select></div>
</li>
<li id="field_31_29" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">How do you want to help? I want to:<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_31_29">
<li class="gchoice gchoice_31_29_1">
<input class="gfield-choice-input" name="input_29.1" type="checkbox"
value="Serve as a member of the Citizen Advisory Council. Advisory Council members should be ready to commit to serving on for at least 2-3 years. The Council meets once a quarter for 1 ½ to 2 hours." id="choice_31_29_1">
<label for="choice_31_29_1" id="label_31_29_1">Serve as a member of the Citizen Advisory Council. Advisory Council members should be ready to commit to serving on for at least 2-3 years. The Council meets once a quarter for 1 ½ to 2
hours.</label>
</li>
<li class="gchoice gchoice_31_29_2">
<input class="gfield-choice-input" name="input_29.2" type="checkbox" value="Make thoughtful recommendations on issues affecting Clinic operations, patient services and quality improvement projects." id="choice_31_29_2">
<label for="choice_31_29_2" id="label_31_29_2">Make thoughtful recommendations on issues affecting Clinic operations, patient services and quality improvement projects.</label>
</li>
<li class="gchoice gchoice_31_29_3">
<input class="gfield-choice-input" name="input_29.3" type="checkbox" value="Strengthen communication and collaboration among patients, families, caregivers and staff." id="choice_31_29_3">
<label for="choice_31_29_3" id="label_31_29_3">Strengthen communication and collaboration among patients, families, caregivers and staff.</label>
</li>
<li class="gchoice gchoice_31_29_4">
<input class="gfield-choice-input" name="input_29.4" type="checkbox" value="Partner with staff on short or long-term projects." id="choice_31_29_4">
<label for="choice_31_29_4" id="label_31_29_4">Partner with staff on short or long-term projects.</label>
</li>
<li class="gchoice gchoice_31_29_5">
<input class="gfield-choice-input" name="input_29.5" type="checkbox" value="Promote clinic services to clinic constituency." id="choice_31_29_5">
<label for="choice_31_29_5" id="label_31_29_5">Promote clinic services to clinic constituency.</label>
</li>
<li class="gchoice gchoice_31_29_6">
<input class="gfield-choice-input" name="input_29.6" type="checkbox" value="Fundraise for special clinic projects." id="choice_31_29_6">
<label for="choice_31_29_6" id="label_31_29_6">Fundraise for special clinic projects.</label>
</li>
<li class="gchoice gchoice_31_29_7">
<input class="gfield-choice-input" name="input_29.7" type="checkbox" value="Staff community health fairs and other educational activities" id="choice_31_29_7">
<label for="choice_31_29_7" id="label_31_29_7">Staff community health fairs and other educational activities</label>
</li>
<li class="gchoice gchoice_31_29_8">
<input class="gfield-choice-input" name="input_29.8" type="checkbox" value="Ensure everyone has access to healthcare by supporting health insurance enrollment outreach efforts." id="choice_31_29_8">
<label for="choice_31_29_8" id="label_31_29_8">Ensure everyone has access to healthcare by supporting health insurance enrollment outreach efforts.</label>
</li>
<li class="gchoice gchoice_31_29_9">
<input class="gfield-choice-input" name="input_29.9" type="checkbox" value="Other issues (please describe):" id="choice_31_29_9">
<label for="choice_31_29_9" id="label_31_29_9">Other issues (please describe):</label>
</li>
</ul>
</div>
</li>
<li id="field_31_38" class="gfield field_sublabel_below field_description_above gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_31_38">Other:</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_38" id="input_31_38" type="text" value="" class="medium form-control" aria-invalid="false" disabled="disabled"> </div>
</li>
<li id="field_31_31" class="gfield gsection field_sublabel_below field_description_above gfield_visibility_visible">
<h2 class="gsection_title">Please tell us about yourself.</h2>
</li>
<li id="field_31_32" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_32">Why do you want to serve on the Community Advisory Committee?<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_textarea form-group"><textarea name="input_32" id="input_31_32" class="textarea medium form-control" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
<li id="field_31_33" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_33">Briefly describe any experience you may have as a community leader
or public speaker.<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_textarea form-group"><textarea name="input_33" id="input_31_33" class="textarea medium form-control" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
<li id="field_31_34" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_34">List employment and/or volunteer experience.<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_textarea form-group"><textarea name="input_34" id="input_31_34" class="textarea medium form-control" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
<li id="field_31_39" class="gfield gsection field_sublabel_below field_description_above gfield_visibility_visible">
<h2 class="gsection_title">Check skills, experience and/or education.</h2>
</li>
<li id="field_31_40" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Special skills<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_31_40">
<li class="gchoice gchoice_31_40_1">
<input class="gfield-choice-input" name="input_40.1" type="checkbox" value="Fundraising" id="choice_31_40_1">
<label for="choice_31_40_1" id="label_31_40_1">Fundraising</label>
</li>
<li class="gchoice gchoice_31_40_2">
<input class="gfield-choice-input" name="input_40.2" type="checkbox" value="Personnel/Human Resources" id="choice_31_40_2">
<label for="choice_31_40_2" id="label_31_40_2">Personnel/Human Resources</label>
</li>
<li class="gchoice gchoice_31_40_3">
<input class="gfield-choice-input" name="input_40.3" type="checkbox" value="Marketing/Public Relations" id="choice_31_40_3">
<label for="choice_31_40_3" id="label_31_40_3">Marketing/Public Relations</label>
</li>
<li class="gchoice gchoice_31_40_4">
<input class="gfield-choice-input" name="input_40.4" type="checkbox" value="Finances" id="choice_31_40_4">
<label for="choice_31_40_4" id="label_31_40_4">Finances</label>
</li>
<li class="gchoice gchoice_31_40_5">
<input class="gfield-choice-input" name="input_40.5" type="checkbox" value="Technology" id="choice_31_40_5">
<label for="choice_31_40_5" id="label_31_40_5">Technology</label>
</li>
<li class="gchoice gchoice_31_40_6">
<input class="gfield-choice-input" name="input_40.6" type="checkbox" value="Legal" id="choice_31_40_6">
<label for="choice_31_40_6" id="label_31_40_6">Legal</label>
</li>
<li class="gchoice gchoice_31_40_7">
<input class="gfield-choice-input" name="input_40.7" type="checkbox" value="Management" id="choice_31_40_7">
<label for="choice_31_40_7" id="label_31_40_7">Management</label>
</li>
<li class="gchoice gchoice_31_40_8">
<input class="gfield-choice-input" name="input_40.8" type="checkbox" value="Other" id="choice_31_40_8">
<label for="choice_31_40_8" id="label_31_40_8">Other</label>
</li>
</ul>
</div>
</li>
<li id="field_31_41" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Professional background<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_31_41">
<li class="gchoice gchoice_31_41_1">
<input class="gfield-choice-input" name="input_41.1" type="checkbox" value="For-profit business" id="choice_31_41_1">
<label for="choice_31_41_1" id="label_31_41_1">For-profit business</label>
</li>
<li class="gchoice gchoice_31_41_2">
<input class="gfield-choice-input" name="input_41.2" type="checkbox" value="Nonprofit" id="choice_31_41_2">
<label for="choice_31_41_2" id="label_31_41_2">Nonprofit</label>
</li>
<li class="gchoice gchoice_31_41_3">
<input class="gfield-choice-input" name="input_41.3" type="checkbox" value="Government" id="choice_31_41_3">
<label for="choice_31_41_3" id="label_31_41_3">Government</label>
</li>
<li class="gchoice gchoice_31_41_4">
<input class="gfield-choice-input" name="input_41.4" type="checkbox" value="Other (please specify):" id="choice_31_41_4">
<label for="choice_31_41_4" id="label_31_41_4">Other (please specify):</label>
</li>
</ul>
</div>
</li>
<li id="field_31_42" class="gfield field_sublabel_below field_description_above gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_31_42">Other:</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_42" id="input_31_42" type="text" value="" class="medium form-control" aria-invalid="false" disabled="disabled"> </div>
</li>
<li id="field_31_43" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Education<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_31_43">
<li class="gchoice gchoice_31_43_1">
<input class="gfield-choice-input" name="input_43.1" type="checkbox" value="Some high school" id="choice_31_43_1">
<label for="choice_31_43_1" id="label_31_43_1">Some high school</label>
</li>
<li class="gchoice gchoice_31_43_2">
<input class="gfield-choice-input" name="input_43.2" type="checkbox" value="High school graduate" id="choice_31_43_2">
<label for="choice_31_43_2" id="label_31_43_2">High school graduate</label>
</li>
<li class="gchoice gchoice_31_43_3">
<input class="gfield-choice-input" name="input_43.3" type="checkbox" value="Some college" id="choice_31_43_3">
<label for="choice_31_43_3" id="label_31_43_3">Some college</label>
</li>
<li class="gchoice gchoice_31_43_4">
<input class="gfield-choice-input" name="input_43.4" type="checkbox" value="Undergraduate college degree" id="choice_31_43_4">
<label for="choice_31_43_4" id="label_31_43_4">Undergraduate college degree</label>
</li>
<li class="gchoice gchoice_31_43_5">
<input class="gfield-choice-input" name="input_43.5" type="checkbox" value="Some graduate coursework" id="choice_31_43_5">
<label for="choice_31_43_5" id="label_31_43_5">Some graduate coursework</label>
</li>
<li class="gchoice gchoice_31_43_6">
<input class="gfield-choice-input" name="input_43.6" type="checkbox" value="Graduate degree or higher" id="choice_31_43_6">
<label for="choice_31_43_6" id="label_31_43_6">Graduate degree or higher</label>
</li>
<li class="gchoice gchoice_31_43_7">
<input class="gfield-choice-input" name="input_43.7" type="checkbox" value="Other (please specify);" id="choice_31_43_7">
<label for="choice_31_43_7" id="label_31_43_7">Other (please specify);</label>
</li>
</ul>
</div>
</li>
<li id="field_31_44" class="gfield field_sublabel_below field_description_above gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_31_44">Other:</label>
<div class="ginput_container ginput_container_text form-group"><input name="input_44" id="input_31_44" type="text" value="" class="medium form-control" aria-invalid="false" disabled="disabled"> </div>
</li>
<li id="field_31_45" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_45">Other affiliations:</label>
<div class="ginput_container ginput_container_textarea form-group"><textarea name="input_45" id="input_31_45" class="textarea medium form-control" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
<li id="field_31_46" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_46">Board or committee service:</label>
<div class="ginput_container ginput_container_textarea form-group"><textarea name="input_46" id="input_31_46" class="textarea medium form-control" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
<li id="field_31_47" class="gfield field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Finally, which locations are you interested in participating:</label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_31_47">
<li class="gchoice gchoice_31_47_1">
<input class="gfield-choice-input" name="input_47.1" type="checkbox" value="Arlington Heights Health Center, 3250 N. Arlington Heights Road, Arlington Height, IL 60074" id="choice_31_47_1">
<label for="choice_31_47_1" id="label_31_47_1">Arlington Heights Health Center, 3250 N. Arlington Heights Road, Arlington Height, IL 60074</label>
</li>
<li class="gchoice gchoice_31_47_2">
<input class="gfield-choice-input" name="input_47.2" type="checkbox" value="Belmont Cragin Health Center, 5501 W. Fullerton, Chicago, IL 60639" id="choice_31_47_2">
<label for="choice_31_47_2" id="label_31_47_2">Belmont Cragin Health Center, 5501 W. Fullerton, Chicago, IL 60639</label>
</li>
<li class="gchoice gchoice_31_47_3">
<input class="gfield-choice-input" name="input_47.3" type="checkbox" value="Blue Island Health Center, 12757 S. Western Avenue, Blue Island, IL 60406" id="choice_31_47_3">
<label for="choice_31_47_3" id="label_31_47_3">Blue Island Health Center, 12757 S. Western Avenue, Blue Island, IL 60406</label>
</li>
<li class="gchoice gchoice_31_47_4">
<input class="gfield-choice-input" name="input_47.4" type="checkbox" value="Cottage Grove Health Center, 1645 S. Cottage Grove Avenue, Ford Heights, IL 60411" id="choice_31_47_4">
<label for="choice_31_47_4" id="label_31_47_4">Cottage Grove Health Center, 1645 S. Cottage Grove Avenue, Ford Heights, IL 60411</label>
</li>
<li class="gchoice gchoice_31_47_5">
<input class="gfield-choice-input" name="input_47.5" type="checkbox" value="Englewood Health Center, 1135 W. 69th Street, Chicago, IL 60621" id="choice_31_47_5">
<label for="choice_31_47_5" id="label_31_47_5">Englewood Health Center, 1135 W. 69th Street, Chicago, IL 60621</label>
</li>
<li class="gchoice gchoice_31_47_6">
<input class="gfield-choice-input" name="input_47.6" type="checkbox" value="North Riverside Health Center, 1800 S. Harlem Avenue, North Riverside, IL 60546" id="choice_31_47_6">
<label for="choice_31_47_6" id="label_31_47_6">North Riverside Health Center, 1800 S. Harlem Avenue, North Riverside, IL 60546</label>
</li>
<li class="gchoice gchoice_31_47_7">
<input class="gfield-choice-input" name="input_47.7" type="checkbox" value="Provident Hospital/Sengstacke Health Center, 500 E. 51st Street, Chicago, IL 60615" id="choice_31_47_7">
<label for="choice_31_47_7" id="label_31_47_7">Provident Hospital/Sengstacke Health Center, 500 E. 51st Street, Chicago, IL 60615</label>
</li>
<li class="gchoice gchoice_31_47_8">
<input class="gfield-choice-input" name="input_47.8" type="checkbox" value="Robbins Health Center, 13450 S. Kedzie Avenue, Robbins, IL 60472" id="choice_31_47_8">
<label for="choice_31_47_8" id="label_31_47_8">Robbins Health Center, 13450 S. Kedzie Avenue, Robbins, IL 60472</label>
</li>
</ul>
</div>
</li>
<li id="field_31_51" class="gfield field_sublabel_below field_description_above hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_31_51">CAPTCHA</label>
<div id="input_31_51" class="ginput_container ginput_recaptcha gform-initialized" data-sitekey="6Lf0r70ZAAAAAF6d7novBTVWZLCp_f4pQuqI3U5b" data-theme="light" data-tabindex="-1" data-size="invisible" data-badge="inline">
<div class="grecaptcha-badge" data-style="inline" style="width: 256px; height: 60px; box-shadow: gray 0px 0px 5px;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Lf0r70ZAAAAAF6d7novBTVWZLCp_f4pQuqI3U5b&co=aHR0cHM6Ly9jb29rY291bnR5aGVhbHRoLm9yZzo0NDM.&hl=en&v=0aeEuuJmrVqDrEL39Fsg5-UJ&theme=light&size=invisible&badge=inline&cb=t9r93fp6swse"
width="256" height="60" role="presentation" name="a-ekkg5t7mt4n9" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"
tabindex="-1"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response-2" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</li>
<li id="field_31_52" class="gfield gform_validation_container field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label" for="input_31_52">Name</label>
<div class="gfield_description" id="gfield_description_31_52">This field is for validation purposes and should be left unchanged.</div>
<div class="ginput_container form-group"><input name="input_52" id="input_31_52" type="text" value="" class="form-control"></div>
</li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_31" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_31"]){return false;} window["gf_submitting_31"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_31"]){return false;} window["gf_submitting_31"]=true; jQuery("#gform_31").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_31" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="31">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_31" value="WyJbXSIsIjdlY2FiOThmMTViNDgwM2YyMzE2NmUzMjg1ODZiNzJiIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_31" id="gform_target_page_number_31" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_31" id="gform_source_page_number_31" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<input type="hidden" name="pum_form_popup_id" value="131985">
</form>Text Content
* COVID-19:
* COVID-19 Testing
* COVID-19 Vaccine Locations
* Vaccine FAQs
* CCH Patient & Visitor Policies
* Vaccine Locations
* FAQs
* Patient & Visitor Policies
* Call 312-864-0200 for an appointment
* MyCookCountyHealth Patient Log-in
* External Provider Application
* Facebook
* Instagram
* Twitter
* YouTube
* Services
* Column 1
* Asthma
* Cancer Care
* Cardiology/Heart & Vascular
* Dental Care (Oral Health)
* Dermatology
* Diabetes & Endocrinology
* Digestive Health (Gastroenterology)
* Ear, Nose & Throat (ENT)
* Emergency Medicine
* Family Medicine
* Foot Care (Podiatry)
* HIV/AIDS Program
* Hypertension (Nephrology)
* Column 2
* Infectious Disease
* Internal Medicine
* Kidney Disease
* Labor & Delivery
* Lung Health (Pulmonary)
* Mental Health & Substance Use
* Neonatal Care
* Neurology & Neurosurgery
* OB/GYN
* Oral and Maxillofacial Surgery
* Orthopedics
* Pain Management Center
* Palliative Care
* Pathology & Laboratory
* Column 3
* Pediatrics
* Pharmacies
* Primary Care
* Radiology & Diagnostic Imaging
* Rheumatology
* Stroke Center
* Surgery
* Therapy Services
* Trauma and Burn
* Urology
* Vision Care (Ophthalmology)
* Women and Children’s Care
* Women, Infants & Children (WIC)
* Patients & Visitors
* MyCookCountyHealth
* COVID-19 Information
* Billing & Insurance
* Request Medical Records
* Patient Rights & Responsibilities
* Healthy Living
* Events
* Health Beat
* Community Relations, Resources and News
* Community Newsletters
* Locations
* Column 1
* COVID-19 Vaccination Sites
* Hospitals
* John H. Stroger, Jr. Hospital of Cook County
* Provident Hospital of Cook County
*
* Pharmacies
* Blue Island Health Center Pharmacy
* Provident Hospital Outpatient Pharmacy
* Stroger Hospital Pharmacy
* Ruth M. Rothstein CORE Center Pharmacy
* Cermak Health Services of Cook County
*
* Health Services
* Cermak Health Services of Cook County
* Cook County Department of Public Health
* Column 3
* Community Health Centers
* Arlington Heights Health Center
* Austin Health Center
* Belmont Cragin Health Center – formerly Logan Square
* Blue Island Health Center – formerly Oak Forest
* Cottage Grove Health Center
* Dr. Jorge Prieto Health Center
* Englewood Health Center
* John Sengstacke Health Center
* Morton East Adolescent Health Center
* North Riverside Health Center – formerly Cicero
* Professional Building
* Robbins Health Center
* Ruth M. Rothstein CORE Center
* Specialty Care Center
* About Us
* About Cook County Health
* Physician Directory
* Making an Impact
* Doing Business with Cook County Health
* Governance
* Human Resources
* Senior Leaders
* Careers
* Nursing Services
* Contribute
* The Change Institute of Cook County Health
* Contact Us
* Education & Research
* Column 1
* Residency Programs
* Anesthesiology
* Colon & Rectal Surgery
* Dermatology
* Emergency Medicine
* Family and Community Medicine
* Internal Medicine
* Primary Care Track
* Categorical Track
* Neurosurgery
* Ophthalmology
* Oral and Maxillofacial Surgery
* Pediatrics
* Pharmacy
* Public Health & Preventive Medicine
* Radiology – Diagnostic
* Trauma & Burn
* Urology
* Column 2
* Fellowship Programs
* Cardiovascular Disease
* Colon & Rectal Surgery
* Emergency Medicine Simulation
* Emergency Ultrasound
* Gastroenterology
* Hematology/Oncology
* Hospice and Palliative Medicine
* Medical Toxicology
* Pain Medicine
* Pediatrics
* Child Abuse
* Neonatal-Perinatal
* Pulmonary, Critical Care and Sleep Medicine
* Surgical Critical Care
* Vitreoretinal Surgery
* Column 3
* Research
* Academic Center Library
* Current Research Projects
* Office of Research & Regulatory Affairs (IRB)
* Research Onboarding
* Collaborative Research Unit
*
* Graduate Medical Education
* Medical Student Rotations
* APRN Fellowship
* Rotating Residents
* Rotating Fellows
* Eligibility & Benefits
* Request Verification
* Education Modules
* ACLS/BLS/PALS Classes
* News
* Press Releases
* Videos
* Media Resource Center
* Search for:
Toggle Navigation
LEARN MORE
COVID-19 VACCINE NOW AVAILABLE
FOR KIDS AGES 5+
LEARN MORE
CONGRATULATIONS TO STROGER HOSPITAL
FOR RECOGNITION BY U.S. NEWS & WORLD REPORT FOR HIGH-RANKING ACHIEVEMENT IN
COPD, HEART ATTACK, HEART FAILURE AND PNEUMONIA CARE.
COVID-19 UPDATE:
WHAT YOU NEED TO KNOW
LEARN MORE
Physician DirectoryCommunity Relations
Search by: SEARCH
YOUR HEALTH. OUR PRIORITY.
FROM PRIMARY CARE TO SPECIALIZED TREATMENT FOR COMPLEX MEDICAL CONDITIONS, COOK
COUNTY HEALTH DELIVERS THE CARE THAT KEEPS YOU HEALTHY.
Cook County Health provides high-quality care to more than 500,000 individuals
through the health system and the health plan. Our teams of doctors, nurses and
medical professionals represent the best in medicine. We continue to modernize
and expand our network of community-based health centers throughout Cook County.
We offer convenient locations and a team of experts ready to offer you and your
family everything from wellness care to emergency medicine.
TO SCHEDULE AN APPOINTMENT WITH A COOK COUNTY HEALTH PHYSICIAN, PLEASE CALL
312-864-0200.
A 180-YEAR HISTORY.
TODAY’S MODERN MEDICINE.
We are proud of our legacy. We thank those who have been on the journey with us
and as we look to the future, we invite you to join us as we elevate the health
of Cook County. Cook County Health is investing in our network and modernizing
services for patients. We’re leading the field in cutting-edge technology,
increased capacity and innovative research. Cook County Health would be honored
to provide your care.
OUR BROAD NETWORK.
MORE OPTIONS FOR YOU.
Our broad network includes two hospitals: John H. Stroger, Jr. Hospital and
Provident Hospital. Patients can also visit more than a dozen community health
centers and the Ruth M. Rothstein CORE Center. Cook County Health is proud of
the work it does through Cook County Department of Public Health and
Correctional Health.
BRINGING HEALTH CARE
TO YOUR COMMUNITY
Cook County Health’s Community Relations team prides itself on being community
advocates and bringing the System’s resources to all Cook County residents.
Our culturally diverse and multilingual team will make sure your health care
questions are answered. We will also provide you with the right resources and
help to resolve your issues and those of your constituents, family friends and
neighbors. Click here to learn more.
ELEVATING THE HEALTH OF COOK COUNTY.
Our mission is to deliver integrated health services with dignity and respect
regardless of a patient’s ability to pay. We seek to create partnerships with
other health providers and communities to enhance the health of the public. We
also advocate for policies that promote the physical, mental and social
well-being of the people of Cook County.
SETTING THE STANDARD IN CARE.
COOK COUNTY HEALTH IS RECOGNIZED FOR PROVIDING A HIGH-QUALITY, SAFE SYSTEM OF
CARE. HERE ARE SOME OF OUR RECOGNITIONS AND ACCREDITATIONS:
AMBULATORY AND COMMUNITY HEALTH NETWORK
* AMBULATORY CARE CERTIFICATION, THE JOINT COMMISSION
* PRIMARY CARE MEDICAL HOME CERTIFICATION, THE JOINT COMMISSION
PROVIDENT HOSPITAL
* HOSPITAL ACCREDITATION, THE JOINT COMMISSION
JOHN H. STROGER, JR. HOSPITAL
* HOSPITAL ACCREDITATION, THE JOINT COMMISSION
* ADVANCED CERTIFICATION FOR PRIMARY STROKE CENTERS, THE JOINT COMMISSION AND
THE AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION
* ACADEMIC COMPREHENSIVE CANCER CARE PROGRAM ACCREDITATION, AMERICAN COLLEGE OF
SURGEONS, COMMISSION ON CANCER; AMERICAN COLLEGE OF SURGEONS
* NATIONAL BURN CENTER VERIFICATION, AMERICAN BURN ASSOCIATION
* LEVEL III NICU AND ADMINISTRATIVE PERINATAL HOSPITAL DESIGNATION, ILLINOIS
DEPARTMENT OF PUBLIC HEALTH
* LEVEL 1 ADULT AND PEDIATRIC TRAUMA CENTER, ILLINOIS DEPARTMENT OF PUBLIC
HEALTH
* DIALYSIS UNIT CERTIFICATION, ILLINOIS DEPARTMENT OF PUBLIC HEALTH
* U.S. NEWS AND WORLD REPORT, HIGH PERFORMING HOSPITAL FOR COPD
* U.S NEWS AND WORLD REPORT, HIGH PERFORMING HOSPITAL FOR HEART ATTACK CARE
* U.S NEWS AND WORLD REPORT, HIGH PERFORMING HOSPITAL FOR HEART FAILURE CARE
* U.S NEWS AND WORLD REPORT, HIGH PERFORMING HOSPITAL FOR PNEUMONIA CARE
* AMERICAN HEART ASSOCIATION, 2020 MISSION: LIFELINE® STEMI RECEIVING CENTER
GOLD RECOGNITION AWARD
* AMERICAN HEART ASSOCIATION, 2020 GET WITH THE GUIDELINES® HEART FAILURE
SILVER AWARD WITH TARGET TYPE 2 DIABETES HONOR ROLL
* HOSPITAL ACCREDITATION, THE JOINT COMMISSION
* ADVANCED CERTIFICATION FOR PRIMARY STROKE CENTERS, THE JOINT COMMISSION AND
THE AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION
* ACADEMIC COMPREHENSIVE CANCER CARE PROGRAM ACCREDITATION, AMERICAN COLLEGE OF
SURGEONS, COMMISSION ON CANCER; AMERICAN COLLEGE OF SURGEONS
* NATIONAL BURN CENTER VERIFICATION, AMERICAN BURN ASSOCIATION
* LEVEL III NICU AND ADMINISTRATIVE PERINATAL HOSPITAL DESIGNATION, ILLINOIS
DEPARTMENT OF PUBLIC HEALTH
* LEVEL 1 ADULT AND PEDIATRIC TRAUMA CENTER,
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
* DIALYSIS UNIT CERTIFICATION,
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
* U.S. NEWS AND WORLD REPORT,
HIGH PERFORMING HOSPITAL FOR COPD
* U.S NEWS AND WORLD REPORT,
HIGH PERFORMING HOSPITAL FOR HEART ATTACK CARE
* U.S NEWS AND WORLD REPORT,
HIGH PERFORMING HOSPITAL FOR HEART ATTACK CARE
* AMERICAN HEART ASSOCIATION, 2020 MISSION: LIFELINE® STEMI RECEIVING CENTER
GOLD RECOGNITION AWARD
* AMERICAN HEART ASSOCIATION, 2020 GET WITH THE GUIDELINES® HEART FAILURE
SILVER AWARD WITH TARGET TYPE 2 DIABETES HONOR ROLL
COOK COUNTY DEPARTMENT OF PUBLIC HEALTH
* ACCREDITED HEALTH DEPARTMENT, PUBLIC HEALTH ACCREDITATION BOARD
BE HEALTHY WITH COUNTYCARE.
COUNTYCARE IS A NO-COST MEDICAID MANAGED CARE HEALTH PLAN FOR PEOPLE IN COOK
COUNTY. COUNTYCARE OFFERS A WIDE RANGE OF HEALTH SERVICES AND EXPERT CARE – AT
NO COST TO MEMBERS.
You must be signed up for Medicaid in order to choose CountyCare as your health
plan. If you are not signed up for Medicaid or if you are unsure, call
CountyCare at (312) 864-8200 for help.
IN THE NEWS.
--------------------------------------------------------------------------------
COOK COUNTY HEALTH ADMINISTERS 1 MILLIONTH DOSE OF COVID-19 VACCINE
April 29, 2022
April 28, 2022– Cook County Health administered its 1 millionth dose of
COVID-19 vaccine this week, making it among the first health systems in the
country to achieve this level of success in vaccinating…
Read More
COOK COUNTY ANNOUNCES PROVIDENT SCHOLARSHIP FUND
April 27, 2022
Nearly $1 million in awards will be given to students pursuing careers in health
care On April 26, Cook County officials joined Cook County Health leaders to
announce a $1M Provident Scholarship Fund to support…
Read More
PRESIDENT PRECKWINKLE ANNOUNCES $12 MILLION INVESTMENT TO LAUNCH BUILDING
HEALTHY COMMUNITIES INITIATIVE
April 12, 2022
Funds available for local organizations to advance COVID-19 recovery and health
equity Today, President Preckwinkle announced new investments to launch the
Building Healthy Communities (BHC) initiative in partnership with Cook County
Health (CCH) and the…
Read More
COOK COUNTY HEALTH ANNOUNCES NEW MRI AT PROVIDENT HOSPITAL
April 4, 2022
On April 1, Cook County leaders came together to announce the installation of a
new MRI at Provident Hospital. Cook County Board President Toni Preckwinkle was
joined by Cook County Commissioners Dennis Deer and Bill…
Read More
COOK COUNTY HEALTH’S STROGER HOSPITAL RANKED #1 MOST RACIALLY INCLUSIVE HOSPITAL
IN IL, #5 IN US
March 22, 2022
Cook County Health’s John H. Stroger, Jr. Hospital has been named the #1 most
racially inclusive hospital in Illinois and #5 most inclusive hospital in the
nation by the Lown Institute Hospitals Index. “Cook County…
Read More
* Cook County Health Employee Login
* Residency/Fellowship Confirmation
* About Cook County Health
* Services
* Patients & Visitors
* Locations
* Education & Research
* News & Media
* Privacy Policy
* Cook County Website
© 2020 Cook County Health. All Rights Reserved.
English
Spanish English
Xandria Hair
COMMUNITY OUTREACH WORKER
EMAIL: XHAIR@COOKCOUNTYHHS.ORG
PHONE: 312-752-2705
--------------------------------------------------------------------------------
AS A NATIVE OF CHICAGO, XANDRIA HAIR DEVELOPED A PASSION FOR IMPROVING HEALTH
OUTCOMES OF MARGINALIZED POPULATIONS. THIS PASSION SPANS ACROSS MANY SECTORS OF
PUBLIC HEALTH AS SHE ADVOCATES FOR ACCESS TO HEALTH EQUITY FROM A SOCIAL AND
RACIAL EQUALITY PERSPECTIVE. SPEARHEADING VARIOUS COMMUNITY OUTREACH INITIATIVES
ALLOWS HER TO ADDRESS HEALTH DISPARITIES THAT IMPACT THE POPULATION SHE SERVES.
XANDRIA HAS EMBRACED HER ROLE AS COMMUNITY OUTREACH WORKER WITH COOK COUNTY
HEALTH AS AN OPPORTUNITY TO ENGAGE AND BUILD RELATIONSHIPS WITH DIVERSE
COMMUNITIES ACROSS THE CHICAGOLAND AREA. SHE EARNED A MASTER OF PUBLIC HEALTH
WITH A CONCENTRATION IN COMMUNITY HEALTH FROM DEPAUL UNIVERSITY. HER LOVE FOR
COMMUNITY IS EVIDENT AS SHE HOSTS THE ANNUAL 4 MEN ONLY HEALTH FAIR AT PROVIDENT
HOSPITAL, AN EVENT THAT BRINGS AWARENESS TO MEN’S HEALTH, PROVIDES ACCESS TO AN
ARRAY OF HEALTH SERVICES AND RESOURCES, AND ALLOWS OPPORTUNITIES FOR STUDENTS AS
A PATHWAY TO CAREERS IN HEALTHCARE.
XANDRIA HAS SPENT HER CAREER SHAPING BOTH THE NON-PROFIT AND HEALTHCARE SECTORS
IN AN EFFORT TO SUPPORT POPULATIONS DISPROPORTIONATELY IMPACTED BY A NUMBER OF
SOCIAL DETERMINANTS OF HEALTH. AT COOK COUNTY HEALTH, HER WORK IMPLEMENTING
COMMUNITY HEALTH PRACTICES HELPS TO INCREASE COLLABORATIVE EFFORTS, ENGAGE
STAKEHOLDERS, AND IMPROVE THE EQUITY AND WELL-BEING OF OUR PATIENT POPULATION.
X
Alice Collins
COMMUNITY OUTREACH WORKER
EMAIL: ACOLLINS3@COOKCOUNTYHHS.ORG
PHONE: 708-633-3602
--------------------------------------------------------------------------------
A NATIVE CHICAGOAN, ALICE FELL IN LOVE WITH COMMUNITY OUTREACH WHEN SHE WAS ONLY
A TEEN. THE YOUNGEST OF 10 CHILDREN, SHE GOT A JOB THROUGH THE CITY OF CHICAGO
SUMMER YOUTH EMPLOYMENT PROGRAM WORKING AT A LOCAL YOUTH SERVICE AGENCY, WHERE
SHE WAS PART OF A TEAM REACHING OUT TO OTHER TEENS AND ENCOURAGING THEM TO AVOID
UNHEALTHY BEHAVIORS. THROUGH THAT EXPERIENCE, AS WELL AS CHALLENGES HER FAMILY
FACED, ALICE DEVELOPED A DEEP ENTHUSIASM FOR SHARING RESOURCES AND INFORMATION
TO MAKE A DIFFERENCE IN THE LIVES OF OTHERS.
ALICE WAS THE FIRST IN HER FAMILY TO OBTAIN A MASTER’S DEGREE AND HAS
WIDE-RANGING EXPERIENCE WORKING IN THE NON-PROFIT AND HEALTHCARE SECTORS. IN HER
PREVIOUS JOB, SHE HELPED HOMEOWNERS EXPERIENCING FORECLOSURE TO AVOID LOSING
THEIR HOMES. DURING HER TIME THERE, ALICE UNCOVERED A LARGE-SCALE FRAUD
OPERATION INVOLVING INDIVIDUALS DEEDING HOMES IN FORECLOSURE TO THEMSELVES. SHE
DILIGENTLY FOLLOWED UP WITH LAW ENFORCEMENT, ELECTED OFFICIALS, AND HUD AND
ADVOCATED ON BEHALF OF THE PROPERTY OWNERS. AFTER A LENGTHY INVESTIGATION, THE
STATE’S ATTORNEY’S OFFICE CHARGED AND CONVICTED FOUR PEOPLE WITH FRAUD, AND THE
VICTIMS WERE ABLE TO SECURE TITLE TO THEIR HOMES. IN RESPONSE, COOK COUNTY
CHANGED THE WAY PROPERTY DEEDS ARE RECORDED, MAKING HOMEOWNERS LESS VULNERABLE
TO THIS TYPE OF THEFT.
AT COOK COUNTY HEALTH, AS PART OF THE OUTREACH TEAM, ALICE HELPS PEOPLE CONNECT
WITH OUR HEALTH SYSTEM AND COUNTYCARE SO THEY CAN ACCESS THE CARE THEY NEED. A
GRADUATE OF THE CCH LEADERSHIP DEVELOPMENT INSTITUTE, SHE IS DEVOTED TO SERVING
OUR PATIENTS AND INVESTING IN THE COMMUNITIES WHERE OUR CLINICS ARE LOCATED. SHE
EVEN ADVOCATED FOR SPONSORSHIP OF A LOCAL YOUTH BASEBALL PROGRAM IN THE FORD
HEIGHTS COMMUNITY AS A WAY FOR YOUTH THERE TO BUILD CONFIDENCE, BE INVOLVED IN
TEAM BUILDING AND DEMONSTRATE COTTAGE GROVE HEALTH CENTER’S INVESTMENT IN THE
COMMUNITY.
ALICE IS COMMITTED TO ENGAGING DIVERSE COMMUNITIES AND IS PASSIONATE ABOUT
SHARING COOK COUNTY HEALTH’S MOTTO, “WE BRING CARE TO THE COMMUNITY”.
X
Marcelino Garcia
DIRECTOR OF COMMUNITY AFFAIRS
EMAIL: MGARCIA6@COOKCOUNTYHHS.ORG
PHONE: 312-864-0928
--------------------------------------------------------------------------------
MARCELINO GARCIA IS COOK COUNTY HEALTH’S DIRECTOR OF COMMUNITY AFFAIRS. AN
ATTORNEY BY TRAINING, HE HAS EXPERTISE IN LOCAL AND INTERNATIONAL GOVERNMENT,
HEALTHCARE AND COMMUNITY AFFAIRS. MARCELINO HAS SPENT MANY YEARS HELPING PEOPLE
WITH THEIR LEGAL DIFFICULTIES THROUGH HIS PUBLIC INTEREST LAW WORK. HE ALSO
WORKS ARDUOUSLY TO BRING RESOURCES TO COMMUNITIES TO ENSURE THEIR ECONOMIC AND
HEALTH DEVELOPMENT.
MARCELINO IS DEVOTED TO PUBLIC SERVICE, HAVING WORKED IN LEADERSHIP ROLES AT
NOT‐FOR‐PROFITS AND GOVERNMENTAL ENTITIES. THROUGH HIS WORK AT THE CHICAGO LEGAL
CLINIC, HE WAS ABLE TO HELP CLIENTS DEAL WITH MORTGAGE FORECLOSURES, DOMESTIC
RELATIONS ISSUES, BANKRUPTCY, AND IMMIGRATION MATTERS. MARCELINO WORKED WITH
MANAGEMENT AND BUDGETS AT THE STATE OF ILLINOIS TO ENSURE THE EFFICIENT
OPERATION OF ENTITIES AND THE AVOIDANCE OF WASTE AT ALL COST. HIS WORK ALSO
FOCUSES ON ENSURING THAT CHICAGO IS RECOGNIZED AS A TRUE INTERNATIONAL CITY WITH
THE MANY DIFFERENT BUSINESS AND CULTURAL ATTRIBUTES THE REGION HAS TO OFFER.
MARCELINO HAS MANY YEARS OF INTERNATIONAL BUSINESS DEVELOPMENT EXPERIENCE,
HAVING WORKED AS SENIOR MANAGER OF INTERNATIONAL RELATIONS FOR CHICAGO 2016, THE
OLYMPIC CANDIDACY COMMITTEE AND AS ASSISTANT MANAGING DIRECTOR OF THE ILLINOIS
OFFICE OF TRADE AND INVESTMENT, WHERE HE WORKED WITH ILLINOIS COMPANIES LOOKING
TO EXPORT TO NEW MARKETS IN THE AMERICAS, AFRICA AND THE MIDDLE EAST.
MARCELINO IS A LICENSED ATTORNEY IN THE STATE OF ILLINOIS AND THE COMMONWEALTH
OF PUERTO RICO. HE EARNED HIS J.D. FROM NORTHWESTERN UNIVERSITY AND HIS
BACHELOR’S DEGREE FROM DARTMOUTH COLLEGE. HE IS FLUENT IN ENGLISH AND SPANISH
AND PROFICIENT IN FRENCH, ITALIAN, AND PORTUGUESE. AN AVID TRAVELER, HE ENJOYS
VISITING NEW AND INTERESTING PLACES TO EXPERIENCE THE WORLD’S SOCIETIES. HE IS
AN AVID SKIER, SWIMMER AND GOURMAND AND ENJOYS INTERACTING WITH PEOPLE FROM ALL
OVER THE WORLD.
X
Join our Community Newsletter Distribution List
* Name*
First Name Last Name
* Title
* Organization
* Email*
* Mobile Phone
* Work Phone
* Work Fax
* Website
* Address*
Street Address Address Line 2 City
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of
ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth
DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth
DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest
VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces
Pacific State ZIP Code
* CAPTCHA
* Name
This field is for validation purposes and should be left unchanged.
X
Request to Participate in a Program
* Name*
First Name Last Name
* Title
* Organization
* Email*
* Mobile Phone
* Work Phone
* Work Fax
* Website
* Address*
Street Address Address Line 2 City
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of
ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth
DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth
DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest
VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces
Pacific State ZIP Code
*
* Event Name
* Date*
MM slash DD slash YYYY
* Start Time
: Hours
Minutes
AM PM
* End Time
: Hours
Minutes
AM PM
* Format*
* Work Shop
* Town Hall
* Video
*
*
* Type of Audience
* How many participants are anticipated?
* Is the event open to the public?
* Yes
* No
* Is a language Interpretation Needed?
* Yes
* No
* Can we publicize the event?
* Yes
* No
* Virtual Platform for event:
* What are the different social media handles for the event?
* Tell us additional information about the event:
* CAPTCHA
* Phone
This field is for validation purposes and should be left unchanged.
X
Community Advisory Councils Application
* Name*
First Name Last Name
* Address*
Street Address Address Line 2 City
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of
ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth
DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth
DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest
VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces
Pacific State ZIP Code
* Home phone
* Cell phone
* Email address*
* Preferred contact (choose one):*
Home phoneCell phoneEmail
* THE FOLLOWING QUESTIONS WILL HELP US GET TO KNOW YOU BETTER.
* Are you a...*
* Patient
* Caregiver or family member of a patient
* Local community leader
* Representative of a religious organization
* Staff member of a community development organization
* Healthcare professional
* If a patient or family member, when was your care experience at this Clinic?
(Check all that apply).
* 2020 to current year
* 2019
* 2018
* 2017 or before
* What language(s) do you speak?*
* We recognize that our community advisors have busy lives. How much time are
you able to commit? (Check one)*
1 to 2 hours per month3 to 4 hours per monthMore than 4 hours per month
* Are you available to serve as an advisor for at least 3 years?*
You can still support the Advisory Council if you answer "no."
YesNo
* How do you want to help? I want to:*
* Serve as a member of the Citizen Advisory Council. Advisory Council
members should be ready to commit to serving on for at least 2-3 years.
The Council meets once a quarter for 1 ½ to 2 hours.
* Make thoughtful recommendations on issues affecting Clinic operations,
patient services and quality improvement projects.
* Strengthen communication and collaboration among patients, families,
caregivers and staff.
* Partner with staff on short or long-term projects.
* Promote clinic services to clinic constituency.
* Fundraise for special clinic projects.
* Staff community health fairs and other educational activities
* Ensure everyone has access to healthcare by supporting health insurance
enrollment outreach efforts.
* Other issues (please describe):
* Other:
* PLEASE TELL US ABOUT YOURSELF.
* Why do you want to serve on the Community Advisory Committee?*
* Briefly describe any experience you may have as a community leader or public
speaker.*
* List employment and/or volunteer experience.*
* CHECK SKILLS, EXPERIENCE AND/OR EDUCATION.
* Special skills*
* Fundraising
* Personnel/Human Resources
* Marketing/Public Relations
* Finances
* Technology
* Legal
* Management
* Other
* Professional background*
* For-profit business
* Nonprofit
* Government
* Other (please specify):
* Other:
* Education*
* Some high school
* High school graduate
* Some college
* Undergraduate college degree
* Some graduate coursework
* Graduate degree or higher
* Other (please specify);
* Other:
* Other affiliations:
* Board or committee service:
* Finally, which locations are you interested in participating:
* Arlington Heights Health Center, 3250 N. Arlington Heights Road, Arlington
Height, IL 60074
* Belmont Cragin Health Center, 5501 W. Fullerton, Chicago, IL 60639
* Blue Island Health Center, 12757 S. Western Avenue, Blue Island, IL 60406
* Cottage Grove Health Center, 1645 S. Cottage Grove Avenue, Ford Heights,
IL 60411
* Englewood Health Center, 1135 W. 69th Street, Chicago, IL 60621
* North Riverside Health Center, 1800 S. Harlem Avenue, North Riverside, IL
60546
* Provident Hospital/Sengstacke Health Center, 500 E. 51st Street, Chicago,
IL 60615
* Robbins Health Center, 13450 S. Kedzie Avenue, Robbins, IL 60472
* CAPTCHA
* Name
This field is for validation purposes and should be left unchanged.
X
Notifications