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https://c1hcm464.caspio.com/dp/d2dbb000d5629d48846c46858f96?fid=Reg681J6E&en=Centering%20Ethics%20&%20Autonomy%20in%20Pregna...
Submission: On September 17 via manual from US — Scanned from US
Submission: On September 17 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
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<span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Do you work in any of the following systems of care? (Mark all that apply)</span>
<br><br>
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for="InsertRecordSys_PublicHealth">Public Health</label></span></div>
<div class="cbFormFieldCell cbFormBlock26_7875230c2558a5" data-cb-row-expanded="14" data-cb-row-collapsed="15" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_Education" id="InsertRecordSys_Education" value="Education"> <label
for="InsertRecordSys_Education">Education (University, College, K-12, or other Education affiliated)</label></span></div>
<div class="cbFormFieldCell cbFormBlock27_7875230c2558a5" data-cb-row-expanded="14" data-cb-row-collapsed="16" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_Pharmacy" id="InsertRecordSys_Pharmacy" value="Pharmacy"> <label
for="InsertRecordSys_Pharmacy">Pharmacy</label></span></div>
<div class="cbFormFieldCell cbFormBlock28_7875230c2558a5" data-cb-row-expanded="15" data-cb-row-collapsed="17" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_FamilyPlanning" id="InsertRecordSys_FamilyPlanning" value="Family Planning"> <label for="InsertRecordSys_FamilyPlanning">Family
Planning</label></span></div>
<div class="cbFormFieldCell cbFormBlock29_7875230c2558a5" data-cb-row-expanded="15" data-cb-row-collapsed="18" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_law" id="InsertRecordSys_law" value="Law"> <label
for="InsertRecordSys_law">Law/Legal</label></span></div>
<div class="cbFormFieldCell cbFormBlock30_7875230c2558a5" data-cb-row-expanded="16" data-cb-row-collapsed="19" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_Health_Care" id="InsertRecordSys_Health_Care" value="Health Care - General"> <label
for="InsertRecordSys_Health_Care">Health Care - General</label></span></div>
<div class="cbFormFieldCell cbFormBlock31_7875230c2558a5" data-cb-row-expanded="16" data-cb-row-collapsed="20" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_Other_dich" id="InsertRecordSys_Other_dich" value="Other"> <label
for="InsertRecordSys_Other_dich">Other System</label></span></div>
<div class="cbFormFieldCell cbFormBlock32_7875230c2558a5" data-cb-row-expanded="17" data-cb-row-collapsed="21" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_HIV" id="InsertRecordSys_HIV" value="HIV"> <label for="InsertRecordSys_HIV">HIV</label></span></div>
<div class="cbFormFieldCell cbFormBlock33_7875230c2558a5" data-cb-row-expanded="17" data-cb-row-collapsed="22" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_SubstanceUse" id="InsertRecordSys_SubstanceUse" value="Substance Use"> <label
for="InsertRecordSys_SubstanceUse">Substance Use</label></span></div>
<div class="cbFormFieldCell cbFormBlock34_7875230c2558a5" data-cb-row-expanded="18" data-cb-row-collapsed="23" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_IPV" id="InsertRecordSys_IPV" value="IPV"> <label for="InsertRecordSys_IPV">Intimate Partner
Violence</label></span></div>
<div class="cbFormFieldCell cbFormBlock35_7875230c2558a5" data-cb-row-expanded="18" data-cb-row-collapsed="24" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even" style="display: none;"><span data-cb-name="cbFormDataCheckbox" class="cbFormData" style="display: none;"><input type="checkbox" name="InsertRecordSys_SUD_MAT" id="InsertRecordSys_SUD_MAT"
value="Medically Assisted Treatment"> <label for="InsertRecordSys_SUD_MAT">Medically Assisted Treatment</label></span></div>
<div class="cbFormFieldCell cbFormBlock36_7875230c2558a5" data-cb-row-expanded="19" data-cb-row-collapsed="25" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_SexualAssault" id="InsertRecordSys_SexualAssault" value=""> <label for="InsertRecordSys_SexualAssault">Sexual Assault</label></span></div>
<div class="cbFormFieldCell cbFormBlock37_7875230c2558a5" data-cb-row-expanded="19" data-cb-row-collapsed="26" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even" style="display: none;"><span data-cb-name="cbFormDataCheckbox" class="cbFormData" style="display: none;"><input type="checkbox" name="InsertRecordSys_SUD_HR" id="InsertRecordSys_SUD_HR"
value="Harm Reduction"> <label for="InsertRecordSys_SUD_HR">Harm Reduction</label></span></div>
<div class="cbFormFieldCell cbFormBlock38_7875230c2558a5" data-cb-row-expanded="20" data-cb-row-collapsed="27" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_MHBH" id="InsertRecordSys_MHBH" value="Mental and/or Behavioral Health"> <label
for="InsertRecordSys_MHBH">Mental and/or Behavioral Health</label></span></div>
<div class="cbFormFieldCell cbFormBlock39_7875230c2558a5" data-cb-row-expanded="20" data-cb-row-collapsed="28" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even" style="display: none;"><span data-cb-name="cbFormDataCheckbox" class="cbFormData" style="display: none;"><input type="checkbox" name="InsertRecordSys_SUD_12step" id="InsertRecordSys_SUD_12step"
value="12 Step Treatment Program"> <label for="InsertRecordSys_SUD_12step">12 Step Treatment Program</label></span></div>
<div class="cbFormFieldCell cbFormBlock40_7875230c2558a5" data-cb-row-expanded="21" data-cb-row-collapsed="29" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSys_Tribal" id="InsertRecordSys_Tribal" value="Tribal"> <label for="InsertRecordSys_Tribal">Native American/Tribal</label></span></div>
<div data-display-order="5" class="cbFormLabelCell cbFormLabel cbFormBlock41_7875230c2558a5" data-cb-row-expanded="21" data-cb-row-collapsed="30" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"></div>
<div class="cbFormFieldCell cbFormBlock42_7875230c2558a5" data-cb-row-expanded="22" data-cb-row-collapsed="31" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"
style="display: none;"><input type="text" maxlength="255" name="InsertRecordParticipant_System_other" id="InsertRecordParticipant_System_other" value="" class="cbFormTextField" size="30" placeholder="Other System of Care"
title="Participant System other" style="display: none;"></div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock43_7875230c2558a5"><input type="hidden" value="" id="HTMLBlock6c46858f96587347816d0c" name="HTMLBlock6c46858f96587347816d0c"><br>
<span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">How would you describe your current role? (Mark all that apply)</span><br>
</div>
<div class="cbFormFieldCell cbFormBlock44_7875230c2558a5" data-cb-row-expanded="24" data-cb-row-collapsed="33" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_WorkWithPts" id="InsertRecordRole_WorkWithPts" value="Works directly with clients"> <label
for="InsertRecordRole_WorkWithPts">I work directly with clients/patients</label></span></div>
<div class="cbFormFieldCell cbFormBlock45_7875230c2558a5" data-cb-row-expanded="24" data-cb-row-collapsed="34" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Physician" id="InsertRecordRole_Physician" value="Physician or Physician’s Assistant">
<label for="InsertRecordRole_Physician">Physician or Physician’s Assistant</label></span></div>
<div class="cbFormFieldCell cbFormBlock46_7875230c2558a5" data-cb-row-expanded="25" data-cb-row-collapsed="35" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_AdminSupport" id="InsertRecordRole_AdminSupport" value="Administration or Support"> <label
for="InsertRecordRole_AdminSupport">Administration or Support</label></span></div>
<div class="cbFormFieldCell cbFormBlock47_7875230c2558a5" data-cb-row-expanded="25" data-cb-row-collapsed="36" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_AP" id="InsertRecordRole_AP" value="APN"> <label for="InsertRecordRole_AP">Advanced Practice
Clinician (NP, APN, PA, CNM, etc.)</label></span></div>
<div class="cbFormFieldCell cbFormBlock48_7875230c2558a5" data-cb-row-expanded="26" data-cb-row-collapsed="37" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Leadership" id="InsertRecordRole_Leadership" value="Leadership"> <label
for="InsertRecordRole_Leadership">Leadership (supervisor, director, executive, etc.)</label></span></div>
<div class="cbFormFieldCell cbFormBlock49_7875230c2558a5" data-cb-row-expanded="26" data-cb-row-collapsed="38" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Nurse" id="InsertRecordRole_Nurse" value="Nurse"> <label for="InsertRecordRole_Nurse">Nurse
(RN, LPN, NP, midwife, etc.)</label></span></div>
<div class="cbFormFieldCell cbFormBlock50_7875230c2558a5" data-cb-row-expanded="27" data-cb-row-collapsed="39" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Board" id="InsertRecordRole_Board" value="Board Member"> <label for="InsertRecordRole_Board">Board Member</label></span></div>
<div class="cbFormFieldCell cbFormBlock51_7875230c2558a5" data-cb-row-expanded="27" data-cb-row-collapsed="40" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_MA" id="InsertRecordRole_MA" value="Medical Assistant (MA)"> <label
for="InsertRecordRole_MA">Medical Assistant (MA)</label></span></div>
<div class="cbFormFieldCell cbFormBlock52_7875230c2558a5" data-cb-row-expanded="28" data-cb-row-collapsed="41" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_SW" id="InsertRecordRole_SW" value="Social Worker"> <label for="InsertRecordRole_SW">Social
Worker</label></span></div>
<div class="cbFormFieldCell cbFormBlock53_7875230c2558a5" data-cb-row-expanded="28" data-cb-row-collapsed="42" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Educator" id="InsertRecordRole_Educator" value="Educator/Education Affiliated"> <label
for="InsertRecordRole_Educator">Educator/Education Affiliated (University, College, K-12, or other institution)</label></span></div>
<div class="cbFormFieldCell cbFormBlock54_7875230c2558a5" data-cb-row-expanded="29" data-cb-row-collapsed="43" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_MBH" id="InsertRecordRole_MBH" value="Mental or Behavioral Health"> <label for="InsertRecordRole_MBH">Mental or Behavioral
Health</label></span></div>
<div class="cbFormFieldCell cbFormBlock55_7875230c2558a5" data-cb-row-expanded="29" data-cb-row-collapsed="44" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_PublicHealth" id="InsertRecordRole_PublicHealth" value="Public Health Professional"> <label
for="InsertRecordRole_PublicHealth">Public Health Professional</label></span></div>
<div class="cbFormFieldCell cbFormBlock56_7875230c2558a5" data-cb-row-expanded="30" data-cb-row-collapsed="45" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Case_manager" id="InsertRecordRole_Case_manager" value="Case Worker or Case Manager"> <label
for="InsertRecordRole_Case_manager">Case Worker or Case Manager</label></span></div>
<div class="cbFormFieldCell cbFormBlock57_7875230c2558a5" data-cb-row-expanded="30" data-cb-row-collapsed="46" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Attorney" id="InsertRecordRole_Attorney" value="Attorney or Lawyer"> <label
for="InsertRecordRole_Attorney">Attorney or Lawyer</label></span></div>
<div class="cbFormFieldCell cbFormBlock58_7875230c2558a5" data-cb-row-expanded="31" data-cb-row-collapsed="47" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_ClientEducator" id="InsertRecordRole_ClientEducator" value="Client Educator/Client Advocate"> <label
for="InsertRecordRole_ClientEducator">Client Educator/Client Advocate</label></span></div>
<div class="cbFormFieldCell cbFormBlock59_7875230c2558a5" data-cb-row-expanded="31" data-cb-row-collapsed="48" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Pharmacist" id="InsertRecordRole_Pharmacist" value="Pharmacist"> <label
for="InsertRecordRole_Pharmacist">Pharmacist</label></span></div>
<div class="cbFormFieldCell cbFormBlock60_7875230c2558a5" data-cb-row-expanded="32" data-cb-row-collapsed="49" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_pt_navigator" id="InsertRecordRole_pt_navigator" value="Patient or Client Navigator"> <label
for="InsertRecordRole_pt_navigator">Patient or Client Navigator</label></span></div>
<div class="cbFormFieldCell cbFormBlock61_7875230c2558a5" data-cb-row-expanded="32" data-cb-row-collapsed="50" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRole_Other" id="InsertRecordRole_Other" value="Other"> <label for="InsertRecordRole_Other">Other
Role</label></span></div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock62_7875230c2558a5"><input type="hidden" value="" id="HTMLBlock6c46858f96594e20181c11" name="HTMLBlock6c46858f96594e20181c11">
<p><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">How would you describe your client population? (select all that apply)</span></p>
</div>
<div class="cbFormFieldCell cbFormBlock63_7875230c2558a5" data-cb-row-expanded="34" data-cb-row-collapsed="52" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordClient_Pop_preg" id="InsertRecordClient_Pop_preg" value="50%+ pregnant"> <label
for="InsertRecordClient_Pop_preg">At least half people who can get pregnant</label></span></div>
<div class="cbFormFieldCell cbFormBlock64_7875230c2558a5" data-cb-row-expanded="34" data-cb-row-collapsed="53" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordClient_Pop_LGBQ" id="InsertRecordClient_Pop_LGBQ" value=">= 10% LGBQ"> <label
for="InsertRecordClient_Pop_LGBQ">at least 10% LGBQ (Lesbian, Gay, Bisexual, Queer or Questioning)</label></span></div>
<div class="cbFormFieldCell cbFormBlock65_7875230c2558a5" data-cb-row-expanded="35" data-cb-row-collapsed="54" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordClient_Pop_Income" id="InsertRecordClient_Pop_Income" value="Mostly lower income"> <label
for="InsertRecordClient_Pop_Income">Mostly lower income</label></span></div>
<div class="cbFormFieldCell cbFormBlock66_7875230c2558a5" data-cb-row-expanded="35" data-cb-row-collapsed="55" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordClient_Pop_Trans" id="InsertRecordClient_Pop_Trans" value=">= 5% trans"> <label for="InsertRecordClient_Pop_Trans">At least 5% Transgender,
Nonbinary, or Gender Expansive</label></span></div>
<div class="cbFormFieldCell cbFormBlock67_7875230c2558a5" data-cb-row-expanded="36" data-cb-row-collapsed="56" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordClient_Pop_BIPOC" id="InsertRecordClient_Pop_BIPOC" value="50%+ BIPOC"> <label
for="InsertRecordClient_Pop_BIPOC">At least half BIPOC (Black, Indigenous, and People of Color)</label></span></div>
<div class="cbFormFieldCell cbFormBlock68_7875230c2558a5" data-cb-row-expanded="36" data-cb-row-collapsed="57" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordClient_Pop_nonenglish" id="InsertRecordClient_Pop_nonenglish" value=">= 20% non-native english ">
<label for="InsertRecordClient_Pop_nonenglish">At least 20% non-native English speaking</label></span></div>
<div class="cbFormNestedTableContainer cbFormBlock69_7875230c2558a5" data-cb-row-expanded="37" data-cb-row-collapsed="58" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordClient_Pop_Rural_percent_7875230c2558a5LabelCell" data-cb-row-expanded="37" data-cb-row-collapsed="58" data-cb-alternate-semantic-row-desktop="Odd"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label id="InsertRecordClient_Pop_Rural_percent_lbl_7875230c2558a5"><br><span
style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">What percentage of your clients live in a rural area?</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="37" data-cb-row-collapsed="58" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordClient_Pop_Rural_percent_lbl_7875230c2558a5" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordClient_Pop_Rural_percent"
id="InsertRecordClient_Pop_Rural_percent0_7875230c2558a5" value="Less than 25%"><label for="InsertRecordClient_Pop_Rural_percent0_7875230c2558a5">Less than 25% </label><input type="radio"
name="InsertRecordClient_Pop_Rural_percent" id="InsertRecordClient_Pop_Rural_percent1_7875230c2558a5" value="25% - 50%"><label for="InsertRecordClient_Pop_Rural_percent1_7875230c2558a5">25% - 50% </label><input type="radio"
name="InsertRecordClient_Pop_Rural_percent" id="InsertRecordClient_Pop_Rural_percent2_7875230c2558a5" value="More than 50%"><label for="InsertRecordClient_Pop_Rural_percent2_7875230c2558a5">More than 50% </label><input
type="radio" name="InsertRecordClient_Pop_Rural_percent" id="InsertRecordClient_Pop_Rural_percent3_7875230c2558a5" value="Don't Know"><label for="InsertRecordClient_Pop_Rural_percent3_7875230c2558a5">Don't Know</label></span>
</fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock70_7875230c2558a5" data-cb-row-expanded="38" data-cb-row-collapsed="59" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_Title_X_7875230c2558a5LabelCell" data-cb-row-expanded="38" data-cb-row-collapsed="59" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label id="InsertRecordParticipant_Title_X_lbl_7875230c2558a5"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Do you
work at a Title X clinic?</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="38" data-cb-row-collapsed="59" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordParticipant_Title_X_lbl_7875230c2558a5" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_Title_X"
id="InsertRecordParticipant_Title_X0_7875230c2558a5" value="Yes"><label for="InsertRecordParticipant_Title_X0_7875230c2558a5">Yes</label><br><input type="radio" name="InsertRecordParticipant_Title_X"
id="InsertRecordParticipant_Title_X1_7875230c2558a5" value="No"><label for="InsertRecordParticipant_Title_X1_7875230c2558a5">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock71_7875230c2558a5" data-cb-row-expanded="39" data-cb-row-collapsed="60" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_FQHC_7875230c2558a5LabelCell" data-cb-row-expanded="39" data-cb-row-collapsed="60" data-cb-alternate-semantic-row-desktop="Odd"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label id="InsertRecordParticipant_FQHC_lbl_7875230c2558a5"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Do you
work at a Federally Qualified Health Center (FQHC)?</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="39" data-cb-row-collapsed="60" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordParticipant_FQHC_lbl_7875230c2558a5" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_FQHC"
id="InsertRecordParticipant_FQHC0_7875230c2558a5" value="Yes"><label for="InsertRecordParticipant_FQHC0_7875230c2558a5">Yes</label><br><input type="radio" name="InsertRecordParticipant_FQHC"
id="InsertRecordParticipant_FQHC1_7875230c2558a5" value="No"><label for="InsertRecordParticipant_FQHC1_7875230c2558a5">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock72_7875230c2558a5" data-cb-row-expanded="40" data-cb-row-collapsed="61" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_listserv_enroll_7875230c2558a5LabelCell" data-cb-row-expanded="40" data-cb-row-collapsed="61" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label id="InsertRecordParticipant_listserv_enroll_lbl_7875230c2558a5"><span
style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Would you like to be informed about future webinars, training opportunities and resources?</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="40" data-cb-row-collapsed="61" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordParticipant_listserv_enroll_lbl_7875230c2558a5" data-cb-name="cbFormDataRadios"><input type="radio"
name="InsertRecordParticipant_listserv_enroll" id="InsertRecordParticipant_listserv_enroll0_7875230c2558a5" value="Yes"><label for="InsertRecordParticipant_listserv_enroll0_7875230c2558a5">Yes</label><br><input type="radio"
name="InsertRecordParticipant_listserv_enroll" id="InsertRecordParticipant_listserv_enroll1_7875230c2558a5" value="No"><label for="InsertRecordParticipant_listserv_enroll1_7875230c2558a5">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock73_7875230c2558a5" data-cb-row-expanded="41" data-cb-row-collapsed="62" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordInterested_CEUs_7875230c2558a5LabelCell" data-cb-row-expanded="41" data-cb-row-collapsed="62" data-cb-alternate-semantic-row-desktop="Odd"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label id="InsertRecordInterested_CEUs_lbl_7875230c2558a5"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Are you
interested in CEUs for this training, if available?</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="41" data-cb-row-collapsed="62" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordInterested_CEUs_lbl_7875230c2558a5" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordInterested_CEUs"
id="InsertRecordInterested_CEUs0_7875230c2558a5" value="Yes"><label for="InsertRecordInterested_CEUs0_7875230c2558a5">Yes</label><br><input type="radio" name="InsertRecordInterested_CEUs"
id="InsertRecordInterested_CEUs1_7875230c2558a5" value="No"><label for="InsertRecordInterested_CEUs1_7875230c2558a5">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock74_7875230c2558a5" data-cb-row-expanded="42" data-cb-row-collapsed="63" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd" style="display: none;">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="42" data-cb-row-collapsed="63" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_degree"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Professional Degree:</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="42" data-cb-row-collapsed="63" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><input type="text"
maxlength="255" name="InsertRecordParticipant_degree" id="InsertRecordParticipant_degree" value="" class="cbFormTextField" size="25" style="display: none;"></div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock75_7875230c2558a5" data-cb-row-expanded="43" data-cb-row-collapsed="64" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even" style="display: none;">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="43" data-cb-row-collapsed="64" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label
for="InsertRecordParticipant_license"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">License #, if seeking CEUs for this training:</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="43" data-cb-row-collapsed="64" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><input type="text"
maxlength="255" name="InsertRecordParticipant_license" id="InsertRecordParticipant_license" value="" class="cbFormTextField" size="25" style="display: none;"></div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock76_7875230c2558a5" data-cb-row-expanded="44" data-cb-row-collapsed="65" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_follow_up_7875230c2558a5LabelCell" data-cb-row-expanded="44" data-cb-row-collapsed="65" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label id="InsertRecordParticipant_follow_up_lbl_7875230c2558a5">
<table style="width: 800px !important;">
<tbody>
<tr>
<td style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold; line-height: 1.5; width: 600px !important;"> Occasionally, we have opportunities to participate in follow-up surveys or interviews, sometimes with
incentives. May we contact you to follow-up about these opportunities in the future?</td>
</tr>
</tbody>
</table>
</label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="44" data-cb-row-collapsed="65" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordParticipant_follow_up_lbl_7875230c2558a5" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_follow_up"
id="InsertRecordParticipant_follow_up0_7875230c2558a5" value="Yes"><label for="InsertRecordParticipant_follow_up0_7875230c2558a5">Yes</label><br><input type="radio" name="InsertRecordParticipant_follow_up"
id="InsertRecordParticipant_follow_up1_7875230c2558a5" value="No"><label for="InsertRecordParticipant_follow_up1_7875230c2558a5">No</label><br></span></fieldset>
</div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock77_7875230c2558a5"><input type="hidden" value="" id="HTMLBlock6c46858f969494ae2a8b47" name="HTMLBlock6c46858f969494ae2a8b47">
<table style="width: 800px !important;">
<tbody>
<tr>
<td><span style="font-style: italic; font-size: 16pt; color: #8c0047">The following demographic questions are for the purposes of advancing Provide's commitment to equity, and to understand who we are serving so we can continue to make
programs more accessible.</span><br> </td>
</tr>
</tbody>
</table>
</div>
<div class="cbFormNestedTableContainer cbFormBlock78_7875230c2558a5" data-cb-row-expanded="46" data-cb-row-collapsed="67" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="46" data-cb-row-collapsed="67" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_Age"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">What is your age?</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="46" data-cb-row-collapsed="67" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><input type="text"
maxlength="2" name="InsertRecordParticipant_Age" id="InsertRecordParticipant_Age" value="" class="cbFormTextField" size="20"></div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock79_7875230c2558a5"><input type="hidden" value="" id="HTMLBlock6c46858f965acc6b51ff7e" name="HTMLBlock6c46858f965acc6b51ff7e"><span
style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold; width: 500px;">How would you describe your gender? (mark all that apply)</span></div>
<div class="cbFormFieldCell cbFormBlock80_7875230c2558a5" data-cb-row-expanded="48" data-cb-row-collapsed="69" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordGender_woman" id="InsertRecordGender_woman" value="Woman"> <label
for="InsertRecordGender_woman">Woman</label></span></div>
<div class="cbFormFieldCell cbFormBlock81_7875230c2558a5" data-cb-row-expanded="48" data-cb-row-collapsed="70" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordGender_nb" id="InsertRecordGender_nb" value="Non-Binary"> <label
for="InsertRecordGender_nb">Non-Binary</label></span></div>
<div class="cbFormFieldCell cbFormBlock82_7875230c2558a5" data-cb-row-expanded="49" data-cb-row-collapsed="71" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordGender_man" id="InsertRecordGender_man" value="Man"> <label for="InsertRecordGender_man">Man</label></span></div>
<div class="cbFormFieldCell cbFormBlock83_7875230c2558a5" data-cb-row-expanded="49" data-cb-row-collapsed="72" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordGender_gq" id="InsertRecordGender_gq" value="Genderqueer"> <label
for="InsertRecordGender_gq">Genderqueer</label></span></div>
<div class="cbFormFieldCell cbFormBlock84_7875230c2558a5" data-cb-row-expanded="50" data-cb-row-collapsed="73" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordGender_trans" id="InsertRecordGender_trans" value="Transgender"> <label
for="InsertRecordGender_trans">Transgender</label></span></div>
<div class="cbFormFieldCell cbFormBlock85_7875230c2558a5" data-cb-row-expanded="50" data-cb-row-collapsed="74" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordGender_other" id="InsertRecordGender_other" value="Other Gender"> <label
for="InsertRecordGender_other">Another gender not listed</label></span></div>
<div class="cbFormFieldCell cbFormBlock86_7875230c2558a5" data-cb-row-expanded="51" data-cb-row-collapsed="75" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordGender_gnc" id="InsertRecordGender_gnc" value="Gender Non-Conforming"> <label for="InsertRecordGender_gnc">Gender
Non-Conforming</label></span></div>
<div data-display-order="13" class="cbFormLabelCell cbFormLabel cbFormBlock87_7875230c2558a5" data-cb-row-expanded="51" data-cb-row-collapsed="76" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"></div>
<div class="cbFormFieldCell cbFormBlock88_7875230c2558a5" data-cb-row-expanded="52" data-cb-row-collapsed="77" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"
style="display: none;"><input type="text" maxlength="255" name="InsertRecordParticipant_gender_other" id="InsertRecordParticipant_gender_other" value="" class="cbFormTextField" size="30" placeholder="Please describe your gender identity"
title="" style="display: none;"></div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock89_7875230c2558a5"><input type="hidden" value="" id="HTMLBlock6c46858f968c11847f5539" name="HTMLBlock6c46858f968c11847f5539">
<p><br><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">How would you describe your race and ethnicity? (mark all that apply)</span></p>
</div>
<div class="cbFormFieldCell cbFormBlock90_7875230c2558a5" data-cb-row-expanded="54" data-cb-row-collapsed="79" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRace_black" id="InsertRecordRace_black" value="Black"> <label for="InsertRecordRace_black">African
American, Black, or African Diaspora</label></span></div>
<div class="cbFormFieldCell cbFormBlock91_7875230c2558a5" data-cb-row-expanded="54" data-cb-row-collapsed="80" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRace_white" id="InsertRecordRace_white" value="White"> <label for="InsertRecordRace_white">White
or Caucasian</label></span></div>
<div class="cbFormFieldCell cbFormBlock92_7875230c2558a5" data-cb-row-expanded="55" data-cb-row-collapsed="81" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRace_asian" id="InsertRecordRace_asian" value="Asian"> <label for="InsertRecordRace_asian">Asian or Asian American</label></span></div>
<div class="cbFormFieldCell cbFormBlock93_7875230c2558a5" data-cb-row-expanded="55" data-cb-row-collapsed="82" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRace_pi" id="InsertRecordRace_pi" value="Pacific Islander"> <label
for="InsertRecordRace_pi">Pacific Islander</label></span></div>
<div class="cbFormFieldCell cbFormBlock94_7875230c2558a5" data-cb-row-expanded="56" data-cb-row-collapsed="83" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRace_aian" id="InsertRecordRace_aian" value="AIAN"> <label for="InsertRecordRace_aian">American
Indian or Alaska Native</label></span></div>
<div class="cbFormFieldCell cbFormBlock95_7875230c2558a5" data-cb-row-expanded="56" data-cb-row-collapsed="84" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRace_mena" id="InsertRecordRace_mena" value="MENA"> <label for="InsertRecordRace_mena">Middle
Eastern or North African</label></span></div>
<div class="cbFormFieldCell cbFormBlock96_7875230c2558a5" data-cb-row-expanded="57" data-cb-row-collapsed="85" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRace_latinx" id="InsertRecordRace_latinx" value="Latinx"> <label for="InsertRecordRace_latinx">Hispanic or Latine/x/a/o</label></span></div>
<div class="cbFormFieldCell cbFormBlock97_7875230c2558a5" data-cb-row-expanded="57" data-cb-row-collapsed="86" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordRace_other" id="InsertRecordRace_other" value="Other"> <label
for="InsertRecordRace_other">Another Race or Ethnicity Not Specified</label></span></div>
<div class="cbFormFieldCell cbFormBlock98_7875230c2558a5" data-cb-row-expanded="58" data-cb-row-collapsed="87" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"
style="display: none;"><input type="text" maxlength="255" name="InsertRecordParticipant_race_other" id="InsertRecordParticipant_race_other" value="" class="cbFormTextField" size="30"
placeholder="Please describe your racial and/or ethnic identity" title="" style="display: none;"></div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock99_7875230c2558a5"><input type="hidden" value="" id="HTMLBlock6c46858f967a738a9f83ec" name="HTMLBlock6c46858f967a738a9f83ec">
<p><br><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">How do you describe your sexual identity? [mark all that apply]</span></p>
</div>
<div class="cbFormFieldCell cbFormBlock100_7875230c2558a5" data-cb-row-expanded="60" data-cb-row-collapsed="89" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd"><span data-cb-name="cbFormDataCheckbox" class="cbFormData"><input type="checkbox" name="InsertRecordSexID_ace" id="InsertRecordSexID_ace" value="Asexual"> <label
for="InsertRecordSexID_ace">Asexual</label></span></div>
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style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Is self managed abortion something you are supposed to report to law enforcement?</span></label></div>
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<table style="width: 800px !important;">
<tbody>
<tr>
<td style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold; line-height: 1.5;">How safe is it for pregnant people to Self Manage their abortion with medication obtained online and not by a clinician?</td>
</tr>
</tbody>
</table>
</label></div>
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<table style="width: 800px !important;">
<tbody>
<tr></tr>
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</section>
</div>
</form>Text Content
Registration: Centering Ethics & Autonomy in Pregnancy Options Counseling 11/20/202 | 2:30:00 PM EST | 1 hours 00 minutes Thank you for your interest in joining us for this training! Please fill out the information below to secure your spot. First Name* Last Name* What name should we use? Email* Verify Email* Phone Number: Zip Code* City State Job title Organization Department or Sattelite Location What is the zipcode of the organization/agency you work for? Is the organization/agency for which you primarily work located in a rural area? Yes No Don't Know Do you work in any of the following systems of care? (Mark all that apply) Abortion Fund or Practical Support Public Health Education (University, College, K-12, or other Education affiliated) Pharmacy Family Planning Law/Legal Health Care - General Other System HIV Substance Use Intimate Partner Violence Medically Assisted Treatment Sexual Assault Harm Reduction Mental and/or Behavioral Health 12 Step Treatment Program Native American/Tribal How would you describe your current role? (Mark all that apply) I work directly with clients/patients Physician or Physician’s Assistant Administration or Support Advanced Practice Clinician (NP, APN, PA, CNM, etc.) Leadership (supervisor, director, executive, etc.) Nurse (RN, LPN, NP, midwife, etc.) Board Member Medical Assistant (MA) Social Worker Educator/Education Affiliated (University, College, K-12, or other institution) Mental or Behavioral Health Public Health Professional Case Worker or Case Manager Attorney or Lawyer Client Educator/Client Advocate Pharmacist Patient or Client Navigator Other Role How would you describe your client population? (select all that apply) At least half people who can get pregnant at least 10% LGBQ (Lesbian, Gay, Bisexual, Queer or Questioning) Mostly lower income At least 5% Transgender, Nonbinary, or Gender Expansive At least half BIPOC (Black, Indigenous, and People of Color) At least 20% non-native English speaking What percentage of your clients live in a rural area? Less than 25% 25% - 50% More than 50% Don't Know Do you work at a Title X clinic? Yes No Do you work at a Federally Qualified Health Center (FQHC)? Yes No Would you like to be informed about future webinars, training opportunities and resources? Yes No Are you interested in CEUs for this training, if available? Yes No Professional Degree: License #, if seeking CEUs for this training: Occasionally, we have opportunities to participate in follow-up surveys or interviews, sometimes with incentives. May we contact you to follow-up about these opportunities in the future? Yes No The following demographic questions are for the purposes of advancing Provide's commitment to equity, and to understand who we are serving so we can continue to make programs more accessible. What is your age? How would you describe your gender? (mark all that apply) Woman Non-Binary Man Genderqueer Transgender Another gender not listed Gender Non-Conforming How would you describe your race and ethnicity? (mark all that apply) African American, Black, or African Diaspora White or Caucasian Asian or Asian American Pacific Islander American Indian or Alaska Native Middle Eastern or North African Hispanic or Latine/x/a/o Another Race or Ethnicity Not Specified How do you describe your sexual identity? [mark all that apply] Asexual Lesbian Bisexual Pansexual Gay Queer Heterosexual Another sexual identity not listed Is self managed abortion something you are supposed to report to law enforcement? Yes No Unsure How safe is it for pregnant people to Self Manage their abortion with medication obtained online and not by a clinician? Very Unsafe Somewhat Unsafe Neither Unsafe nor Safe Somewhat Safe Very Safe How did you hear about this webinar? Provide Email Instagram Provide Website In-Person Outreach by Provide Staff Colleague Conference Friend Other Website Facebook