c1hcm464.caspio.com
Open in
urlscan Pro
54.86.58.154
Public Scan
URL:
https://c1hcm464.caspio.com/dp/d2dbb000d5629d48846c46858f96?fid=RegUBNEXN&en=New%20Orleans%20Abortion%20Referrals%20Training
Submission: On May 22 via manual from US — Scanned from DE
Submission: On May 22 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://c1hcm464.caspio.com/dp/d2dbb000d5629d48846c46858f96?fid=RegUBNEXN&en=New+Orleans+Abortion+Referrals+Training
<form method="post" id="caspioform" action="https://c1hcm464.caspio.com/dp/d2dbb000d5629d48846c46858f96?fid=RegUBNEXN&en=New+Orleans+Abortion+Referrals+Training" style="margin: 0px;"><input type="hidden" name="cbUniqueFormId"
id="cbUniqueFormId_6c217765776402" value="_6c217765776402"><input type="hidden" name="AppKey" value="d2dbb000d5629d48846c46858f96"><input type="hidden" name="PrevPageID" value="3"><input type="hidden" name="cbPageType" value="Insert"><input
type="hidden" name="ClientQueryString" value="fid=RegUBNEXN&en=New+Orleans+Abortion+Referrals+Training"><input type="hidden" name="pathname" value="https://c1hcm464.caspio.com/dp/d2dbb000d5629d48846c46858f96"><input type="hidden"
name="Mod0InsertRecord" value="1"><input type="hidden" name="Mod0InsertRecordPageID" value="3"><input type="hidden" name="cbAP" value="Caspio"><input type="hidden" id="InsertRecordEvent_ID_6c217765776402" name="InsertRecordEvent_ID"
value="95836590"><input type="hidden" id="InsertRecordEvent_Type_6c217765776402" name="InsertRecordEvent_Type" value="Referrals Training"><input type="hidden" id="InsertRecordReg_Form_ID" name="InsertRecordReg_Form_ID" value="RegUBNEXN"><input
type="hidden" id="InsertRecordEvent_Name" name="InsertRecordEvent_Name" value="New Orleans Abortion Referrals Training"><input type="hidden" id="cbParamVirtual1_6c217765776402" name="cbParamVirtual1" value=""><input type="hidden"
id="cbParamVirtual3_6c217765776402" name="cbParamVirtual3" value=""><input type="hidden" id="cbParamVirtual5_6c217765776402" name="cbParamVirtual5" value="5/29/2024 11:00:00 AM"><input type="hidden" id="cbParamVirtual6_6c217765776402"
name="cbParamVirtual6" value="5/29/2024 2:00:00 PM"><input type="hidden" id="cbParamVirtual7_6c217765776402" name="cbParamVirtual7" value=""><input type="hidden" id="cbParamVirtual8_6c217765776402" name="cbParamVirtual8" value=""><input
type="hidden" id="InsertRecordWebinar_url_6c217765776402" name="InsertRecordWebinar_url" value=""><input type="hidden" id="InsertRecordEvent_date_6c217765776402" name="InsertRecordEvent_date" value="5/29/2024 11:00:00 AM"><input type="hidden"
id="InsertRecordEnd_time_6c217765776402" name="InsertRecordEnd_time" value="5/29/2024 2:00:00 PM"><input type="hidden" id="InsertRecordEvent_Name_branded_6c217765776402" name="InsertRecordEvent_Name_branded" value=""><input type="hidden"
id="InsertRecordEvent_decription_6c217765776402" name="InsertRecordEvent_decription" value="">
<div style="display: table;">
<section data-cb-name="cbTable" id="cbTable_6c217765776402" class="cbFormSection_6c217765776402">
<div class="cbHTMLBlockContainer cbFormData cbFormBlock1_6c217765776402"><input type="hidden" value="" id="HTMLBlock6c46858f9681612b8dc5d6" name="HTMLBlock6c46858f9681612b8dc5d6">
<div style="margin-left: 600px;"><img alt="Provide logo" src="https://providecare.org/wp-content/uploads/2022/01/Provide-30yearslogo-website.png" style="width: 256px; height: 119px;"></div>
</div>
<div class="cbFormFieldCell cbFormBlock2_6c217765776402" data-cb-row-expanded="2" data-cb-row-collapsed="2" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even">
<span class="cbFormData cbFormCalculatedField" id="cbParamVirtual2@Data_6c217765776402" style=""><span style="color:#8c0047; font-size: 36px;"><b>Registration: </b></span><br><br><span
style="color:#666; font-size: 20px; padding-top: 5%;"><b>5/29/2024 | 11:00:00 AM EST | 3 hours 00 minutes</b></span></span><input type="hidden" id="cbParamVirtual2_6c217765776402" name="cbParamVirtual2"
value="<span style="color:#8c0047; font-size: 36px;"><b>Registration: </b></span><br><br><span style="color:#666; font-size: 20px; padding-top: 5%;"><b>5/29/2024 | 11:00:00 AM EST | 3 hours 00 minutes</span></b>">
<div class="cbFormData cbFormCalculatedField" style="display: none;"></div>
</div>
<div class="cbFormFieldCell cbFormBlock3_6c217765776402" data-cb-row-expanded="3" data-cb-row-collapsed="3" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd">
<span class="cbFormData cbFormCalculatedField" id="cbParamVirtual4@Data_6c217765776402" style=""><span
style="color:#666; font-size: 16px;"><b>Thank you for your interest in joining us for this training! Please fill out the information below to secure your spot.</b></span><br><br></span><input type="hidden"
id="cbParamVirtual4_6c217765776402" name="cbParamVirtual4"
value="<span style="color:#666; font-size: 16px;"><b>Thank you for your interest in joining us for this training! Please fill out the information below to secure your spot.</b></span><br><br>">
<div class="cbFormData cbFormCalculatedField" style="display: none;"></div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock4_6c217765776402" data-cb-row-expanded="4" data-cb-row-collapsed="4" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormBlock5_6c217765776402">
<div class="cbFormLabelCell cbFormLabelRequired" data-cb-row-expanded="4" data-cb-row-collapsed="4" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even">
<label for="InsertRecordParticipant_First_Name"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">First Name</span><span class="cbFormRequiredMarker">*</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="4" data-cb-row-collapsed="4" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><input type="text"
maxlength="255" name="InsertRecordParticipant_First_Name" id="InsertRecordParticipant_First_Name" value="" class="cbFormTextField" size="30"></div>
</div>
<div class="cbFormBlock6_6c217765776402">
<div class="cbFormLabelCell cbFormLabelRequired" data-cb-row-expanded="4" data-cb-row-collapsed="4" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even">
<label for="InsertRecordParticipant_Last_Name"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Last Name</span><span class="cbFormRequiredMarker">*</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="4" data-cb-row-collapsed="4" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><input type="text"
maxlength="255" name="InsertRecordParticipant_Last_Name" id="InsertRecordParticipant_Last_Name" value="" class="cbFormTextField" size="30"></div>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock7_6c217765776402" data-cb-row-expanded="5" data-cb-row-collapsed="5" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd">
<div class="cbFormBlock8_6c217765776402">
<div class="cbFormLabelCell cbFormLabelRequired" data-cb-row-expanded="5" data-cb-row-collapsed="5" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_email"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Email</span><span class="cbFormRequiredMarker">*</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="5" data-cb-row-collapsed="5" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><input type="email"
maxlength="255" name="InsertRecordParticipant_email" id="InsertRecordParticipant_email" value="" class="cbFormTextField" size="30"></div>
</div>
<div class="cbFormBlock9_6c217765776402">
<div class="cbFormLabelCell cbFormLabelRequired" data-cb-row-expanded="5" data-cb-row-collapsed="5" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_email@Confirm"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Verify Email</span><span class="cbFormRequiredMarker">*</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="5" data-cb-row-collapsed="5" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><input type="text"
maxlength="255" name="InsertRecordParticipant_email@Confirm" id="InsertRecordParticipant_email@Confirm" value="" class="cbFormTextField" size="30"></div>
</div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock10_6c217765776402"><input type="hidden" value="" id="HTMLBlock6c46858f965c7c2cca080e" name="HTMLBlock6c46858f965c7c2cca080e"></div>
<div class="cbFormNestedTableContainer cbFormBlock11_6c217765776402" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd">
<div class="cbFormBlock12_6c217765776402">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_phone"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold; ">Phone Number:</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><input type="text"
maxlength="14" name="InsertRecordParticipant_phone" id="InsertRecordParticipant_phone" value="" class="cbFormTextField" size="20"></div>
</div>
<div class="cbFormBlock13_6c217765776402">
<div class="cbFormLabelCell cbFormLabelRequired" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_Zip_6c217765776402"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Zip Code</span><span class="cbFormRequiredMarker">*</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><input type="text"
maxlength="255" name="InsertRecordParticipant_Zip" id="InsertRecordParticipant_Zip_6c217765776402" value="" class="cbFormTextField" size="10" autocomplete="off"></div>
</div>
<div class="cbFormBlock14_6c217765776402">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_City_6c217765776402"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">City</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><input type="text"
maxlength="255" name="InsertRecordParticipant_City" id="InsertRecordParticipant_City_6c217765776402" value="" class="cbFormTextField" size="27" autocomplete="off"></div>
</div>
<div class="cbFormBlock15_6c217765776402">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_state_6c217765776402"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">State</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="7" data-cb-row-collapsed="7" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><input type="text"
maxlength="255" name="InsertRecordParticipant_state" id="InsertRecordParticipant_state_6c217765776402" value="" class="cbFormTextField" size="10" autocomplete="off"></div>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock16_6c217765776402" data-cb-row-expanded="8" data-cb-row-collapsed="8" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormBlock17_6c217765776402">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="8" data-cb-row-collapsed="8" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label
for="InsertRecordParticipant_Job_Title"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Job title</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="8" data-cb-row-collapsed="8" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><input type="text"
maxlength="255" name="InsertRecordParticipant_Job_Title" id="InsertRecordParticipant_Job_Title" value="" class="cbFormTextField" size="50"></div>
</div>
<div class="cbFormBlock18_6c217765776402">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="8" data-cb-row-collapsed="8" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label
for="InsertRecordParticipant_organization_6c217765776402"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Organization (Spell out all acronyms)</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="8" data-cb-row-collapsed="8" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><input type="text"
maxlength="255" name="InsertRecordParticipant_organization" id="InsertRecordParticipant_organization_6c217765776402" value="" class="cbFormTextField" size="55" autocomplete="off"></div>
</div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock19_6c217765776402"><input type="hidden" value="" id="HTMLBlock6c46858f96860069838995" name="HTMLBlock6c46858f96860069838995"><br>
<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>
</div>
<div class="cbFormFieldCell cbFormBlock20_6c217765776402" data-cb-row-expanded="10" data-cb-row-collapsed="10" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbComboBoxContainer" style="position: relative;">
<div id="ComboBoxInsertRecordParticipant_System_6c217765776402">
<div class="ListData ListBox cbFormMultiSelect" tabindex="0" data-cb-name="MultiSelectListBox" style="width: 700px; min-width: 10px; height: 370px; background-color: rgb(255, 255, 255);">
<div class="Body" style="overflow-y: hidden;">
<div style="width: 100%;">
<div style="overflow-y: auto; height: 225px;">
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_0"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_0" style="vertical-align: middle;">Family Planning</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_1"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_1" style="vertical-align: middle;">Health Care</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_2"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_2" style="vertical-align: middle;">Intimate Partner Violence</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_3"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_3" style="vertical-align: middle;">Sexual Assault</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_4"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_4" style="vertical-align: middle;">Education</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_5"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_5" style="vertical-align: middle;">HIV</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_6"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_6" style="vertical-align: middle;">Mental and Behavioral Health</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_7"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_7" style="vertical-align: middle;">Native American/Tribal</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_8"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_8" style="vertical-align: middle;">Pharmacy</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_9"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_9" style="vertical-align: middle;">Abortion Fund</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_10"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_10" style="vertical-align: middle;">Public Health</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_11"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_11" style="vertical-align: middle;">Law/Policy</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_12"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_12" style="vertical-align: middle;">Substance Use Disorder</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_6c217765776402_unchecked_13"><label for="InsertRecordParticipant_System_6c217765776402_unchecked_13" style="vertical-align: middle;">Other</label></div>
</div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="InsertRecordParticipant_System" id="InsertRecordParticipant_System_6c217765776402" value="">
</div>
<div class="cbFormFieldCell cbFormBlock21_6c217765776402" data-cb-row-expanded="11" data-cb-row-collapsed="11" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"
style="display: none !important;">
<div class="cbComboBoxContainer" style="position: relative; display: none !important;">
<div id="ComboBoxInsertRecordParticipant_System_SUD_6c217765776402">
<div class="ListData ListBox cbFormMultiSelect" tabindex="0" data-cb-name="MultiSelectListBox" style="width: 900px; min-width: 10px; height: 187px; background-color: rgb(255, 255, 255);">
<div class="Body" style="overflow-y: hidden;">
<div style="width: 100%;">
<div style="overflow-y: auto; height: 100px;">
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_SUD_6c217765776402_unchecked_0"><label for="InsertRecordParticipant_System_SUD_6c217765776402_unchecked_0" style="vertical-align: middle;">Medication Assisted Treatment
(Methadone/Suboxone/Other)</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_SUD_6c217765776402_unchecked_1"><label for="InsertRecordParticipant_System_SUD_6c217765776402_unchecked_1" style="vertical-align: middle;">Harm Reduction</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_System_SUD_6c217765776402_unchecked_2"><label for="InsertRecordParticipant_System_SUD_6c217765776402_unchecked_2" style="vertical-align: middle;">12 Step Addiction Treatment</label></div>
</div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="InsertRecordParticipant_System_SUD" id="InsertRecordParticipant_System_SUD_6c217765776402" value="" style="display: none;">
</div>
<div class="cbFormFieldCell cbFormBlock22_6c217765776402" data-cb-row-expanded="12" data-cb-row-collapsed="12" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even" style="display: none;"><input type="text" maxlength="255" name="InsertRecordParticipant_System_other" id="InsertRecordParticipant_System_other" value="" class="cbFormTextField" size="25"
placeholder="Other systems of care" title="" style="display: none;"></div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock23_6c217765776402"><input type="hidden" value="" id="HTMLBlock6c46858f963b9550a1b99d" name="HTMLBlock6c46858f963b9550a1b99d"><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 cbFormBlock24_6c217765776402" data-cb-row-expanded="14" data-cb-row-collapsed="14" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbComboBoxContainer" style="position: relative;">
<div id="ComboBoxInsertRecordParticipant_Role_6c217765776402">
<div class="ListData ListBox cbFormMultiSelect" tabindex="0" data-cb-name="MultiSelectListBox" style="width: 700px; min-width: 10px; height: 395px; background-color: rgb(255, 255, 255);">
<div class="Body" style="overflow-y: hidden;">
<div style="width: 100%;">
<div style="overflow-y: auto; height: 250px;">
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_0"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_0" style="vertical-align: middle;">I work directly with clients/patients</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_1"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_1" style="vertical-align: middle;">Administration or Support</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_2"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_2" style="vertical-align: middle;">Leadership (supervisor, director, executive, etc.)</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_3"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_3" style="vertical-align: middle;">Board Member</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_4"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_4" style="vertical-align: middle;">Social Worker</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_5"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_5" style="vertical-align: middle;">Mental or Behavioral Health Provider</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_6"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_6" style="vertical-align: middle;">Case Worker or Case Manager</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_7"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_7" style="vertical-align: middle;">Client Educator or Client Advocate</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_8"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_8" style="vertical-align: middle;">Physician or Physician’s Assistant</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_9"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_9" style="vertical-align: middle;">Nurse (RN, LPN, NP, midwife, etc.)</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_10"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_10" style="vertical-align: middle;">Medical Assistant (MA)</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_11"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_11" style="vertical-align: middle;">Educator/Education Affiliated</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_12"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_12" style="vertical-align: middle;">Public Health Worker</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_13"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_13" style="vertical-align: middle;">Pharmacist</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_14"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_14" style="vertical-align: middle;">Attorney</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_Role_6c217765776402_unchecked_15"><label for="InsertRecordParticipant_Role_6c217765776402_unchecked_15" style="vertical-align: middle;">Other</label></div>
</div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="InsertRecordParticipant_Role" id="InsertRecordParticipant_Role_6c217765776402" value="">
</div>
<div class="cbFormFieldCell cbFormBlock25_6c217765776402" data-cb-row-expanded="15" data-cb-row-collapsed="15" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"
style="display: none;"><input type="text" maxlength="255" name="InsertRecordRole_Other" id="InsertRecordRole_Other" value="" class="cbFormTextField" size="25" placeholder="Other role" title="" style="display: none;"></div>
<div class="cbFormNestedTableContainer cbFormBlock26_6c217765776402" data-cb-row-expanded="16" 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">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_client_pop_6c217765776402LabelCell" data-cb-row-expanded="16" 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 style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">How would you describe your client population? (select all that
apply)</span></div>
<div class="cbFormFieldCell" data-cb-row-expanded="16" 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">
<div class="cbComboBoxContainer" style="position: relative;">
<div id="ComboBoxInsertRecordParticipant_client_pop_6c217765776402">
<div class="ListData ListBox cbFormMultiSelect" tabindex="0" data-cb-name="MultiSelectListBox" style="width: 379px; min-width: 10px; height: 203px; background-color: rgb(255, 255, 255);">
<div class="Body" style="overflow-y: hidden;">
<div style="width: 100%;">
<div style="overflow-y: auto; height: 203px;">
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_client_pop_6c217765776402_unchecked_0"><label for="InsertRecordParticipant_client_pop_6c217765776402_unchecked_0" style="vertical-align: middle;">Mostly rural</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_client_pop_6c217765776402_unchecked_1"><label for="InsertRecordParticipant_client_pop_6c217765776402_unchecked_1" style="vertical-align: middle;">Mostly lower income</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_client_pop_6c217765776402_unchecked_2"><label for="InsertRecordParticipant_client_pop_6c217765776402_unchecked_2" style="vertical-align: middle;">At least half people who can get pregnant</label>
</div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_client_pop_6c217765776402_unchecked_3"><label for="InsertRecordParticipant_client_pop_6c217765776402_unchecked_3" style="vertical-align: middle;">At least half Black, Indigenous, and People of
Color</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_client_pop_6c217765776402_unchecked_4"><label for="InsertRecordParticipant_client_pop_6c217765776402_unchecked_4" style="vertical-align: middle;">20% or more non-native English speaking</label>
</div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_client_pop_6c217765776402_unchecked_5"><label for="InsertRecordParticipant_client_pop_6c217765776402_unchecked_5" style="vertical-align: middle;">10% or more LGBQ (Lesbian, Gay, Bisexual, or
Queer)</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_client_pop_6c217765776402_unchecked_6"><label for="InsertRecordParticipant_client_pop_6c217765776402_unchecked_6" style="vertical-align: middle;">5% or more transgender or gender expansive</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="InsertRecordParticipant_client_pop" id="InsertRecordParticipant_client_pop_6c217765776402" value="">
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock27_6c217765776402" data-cb-row-expanded="17" 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">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_Title_X_6c217765776402LabelCell" data-cb-row-expanded="17" 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"><label id="InsertRecordParticipant_Title_X_lbl_6c217765776402"><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="17" 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">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordParticipant_Title_X_lbl_6c217765776402" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_Title_X"
id="InsertRecordParticipant_Title_X0_6c217765776402" value="Yes"><label for="InsertRecordParticipant_Title_X0_6c217765776402">Yes</label><br><input type="radio" name="InsertRecordParticipant_Title_X"
id="InsertRecordParticipant_Title_X1_6c217765776402" value="No"><label for="InsertRecordParticipant_Title_X1_6c217765776402">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock28_6c217765776402" data-cb-row-expanded="18" data-cb-row-collapsed="18" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_FQHC_6c217765776402LabelCell" data-cb-row-expanded="18" data-cb-row-collapsed="18" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label id="InsertRecordParticipant_FQHC_lbl_6c217765776402"><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="18" data-cb-row-collapsed="18" data-cb-alternate-semantic-row-desktop="Even" 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_6c217765776402" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_FQHC"
id="InsertRecordParticipant_FQHC0_6c217765776402" value="Yes"><label for="InsertRecordParticipant_FQHC0_6c217765776402">Yes</label><br><input type="radio" name="InsertRecordParticipant_FQHC"
id="InsertRecordParticipant_FQHC1_6c217765776402" value="No"><label for="InsertRecordParticipant_FQHC1_6c217765776402">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock29_6c217765776402" data-cb-row-expanded="19" data-cb-row-collapsed="19" data-cb-alternate-semantic-row-desktop="Odd" 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_6c217765776402LabelCell" data-cb-row-expanded="19" data-cb-row-collapsed="19" data-cb-alternate-semantic-row-desktop="Odd"
data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label id="InsertRecordParticipant_listserv_enroll_lbl_6c217765776402"><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="19" data-cb-row-collapsed="19" data-cb-alternate-semantic-row-desktop="Odd" 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_6c217765776402" data-cb-name="cbFormDataRadios"><input type="radio"
name="InsertRecordParticipant_listserv_enroll" id="InsertRecordParticipant_listserv_enroll0_6c217765776402" value="Yes"><label for="InsertRecordParticipant_listserv_enroll0_6c217765776402">Yes</label><br><input type="radio"
name="InsertRecordParticipant_listserv_enroll" id="InsertRecordParticipant_listserv_enroll1_6c217765776402" value="No"><label for="InsertRecordParticipant_listserv_enroll1_6c217765776402">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock30_6c217765776402" data-cb-row-expanded="20" 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">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordInterested_CEUs_6c217765776402LabelCell" data-cb-row-expanded="20" 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"><label id="InsertRecordInterested_CEUs_lbl_6c217765776402"><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="20" 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">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordInterested_CEUs_lbl_6c217765776402" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordInterested_CEUs"
id="InsertRecordInterested_CEUs0_6c217765776402" value="Yes"><label for="InsertRecordInterested_CEUs0_6c217765776402">Yes</label><br><input type="radio" name="InsertRecordInterested_CEUs"
id="InsertRecordInterested_CEUs1_6c217765776402" value="No"><label for="InsertRecordInterested_CEUs1_6c217765776402">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock31_6c217765776402" data-cb-row-expanded="21" 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" style="display: none;">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="21" 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"><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="21" 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"><input type="text"
maxlength="255" name="InsertRecordParticipant_degree" id="InsertRecordParticipant_degree" value="" class="cbFormTextField" size="25" style="display: none;"></div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock32_6c217765776402" data-cb-row-expanded="22" data-cb-row-collapsed="22" data-cb-alternate-semantic-row-desktop="Even" 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="22" data-cb-row-collapsed="22" data-cb-alternate-semantic-row-desktop="Even" 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="22" data-cb-row-collapsed="22" data-cb-alternate-semantic-row-desktop="Even" 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 cbFormBlock33_6c217765776402" data-cb-row-expanded="23" data-cb-row-collapsed="23" data-cb-alternate-semantic-row-desktop="Odd" 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_6c217765776402LabelCell" data-cb-row-expanded="23" data-cb-row-collapsed="23" data-cb-alternate-semantic-row-desktop="Odd"
data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label id="InsertRecordParticipant_follow_up_lbl_6c217765776402">
<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="23" data-cb-row-collapsed="23" data-cb-alternate-semantic-row-desktop="Odd" 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_6c217765776402" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_follow_up"
id="InsertRecordParticipant_follow_up0_6c217765776402" value="Yes"><label for="InsertRecordParticipant_follow_up0_6c217765776402">Yes</label><br><input type="radio" name="InsertRecordParticipant_follow_up"
id="InsertRecordParticipant_follow_up1_6c217765776402" value="No"><label for="InsertRecordParticipant_follow_up1_6c217765776402">No</label><br></span></fieldset>
</div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock34_6c217765776402"><input type="hidden" value="" id="HTMLBlock6c46858f96802c7c81e136" name="HTMLBlock6c46858f96802c7c81e136">
<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 cbFormBlock35_6c217765776402" data-cb-row-expanded="25" 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">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="25" 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"><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="25" 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"><input type="text"
maxlength="2" name="InsertRecordParticipant_Age" id="InsertRecordParticipant_Age" value="" class="cbFormTextField" size="20"></div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock36_6c217765776402" data-cb-row-expanded="26" data-cb-row-collapsed="26" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_gender_6c217765776402LabelCell" data-cb-row-expanded="26" data-cb-row-collapsed="26" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><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" data-cb-row-expanded="26" data-cb-row-collapsed="26" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even">
<div class="cbComboBoxContainer" style="position: relative;">
<div id="ComboBoxInsertRecordParticipant_gender_6c217765776402">
<div class="ListData ListBox cbFormMultiSelect" tabindex="0" data-cb-name="MultiSelectListBox" style="width: 600px; min-width: 10px; height: 411px; background-color: rgb(255, 255, 255);">
<div class="Body" style="overflow-y: hidden;">
<div style="width: 100%;">
<div style="overflow-y: auto; height: 150px;">
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_gender_6c217765776402_unchecked_0"><label for="InsertRecordParticipant_gender_6c217765776402_unchecked_0" style="vertical-align: middle;">Agender</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_gender_6c217765776402_unchecked_1"><label for="InsertRecordParticipant_gender_6c217765776402_unchecked_1" style="vertical-align: middle;">Gender Non-Conforming</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_gender_6c217765776402_unchecked_2"><label for="InsertRecordParticipant_gender_6c217765776402_unchecked_2" style="vertical-align: middle;">Genderqueer</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_gender_6c217765776402_unchecked_3"><label for="InsertRecordParticipant_gender_6c217765776402_unchecked_3" style="vertical-align: middle;">Man</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_gender_6c217765776402_unchecked_4"><label for="InsertRecordParticipant_gender_6c217765776402_unchecked_4" style="vertical-align: middle;">Non-binary</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_gender_6c217765776402_unchecked_5"><label for="InsertRecordParticipant_gender_6c217765776402_unchecked_5" style="vertical-align: middle;">Transgender</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_gender_6c217765776402_unchecked_6"><label for="InsertRecordParticipant_gender_6c217765776402_unchecked_6" style="vertical-align: middle;">Woman</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_gender_6c217765776402_unchecked_7"><label for="InsertRecordParticipant_gender_6c217765776402_unchecked_7" style="vertical-align: middle;">An identity not listed/self-identify:</label></div>
</div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="InsertRecordParticipant_gender" id="InsertRecordParticipant_gender_6c217765776402" value="">
</div>
</div>
<div class="cbFormFieldCell cbFormBlock37_6c217765776402" data-cb-row-expanded="27" data-cb-row-collapsed="27" data-cb-alternate-semantic-row-desktop="Odd" 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="25" placeholder="Please describe your gender identity"
title="" style="display: none;"></div>
<div class="cbFormNestedTableContainer cbFormBlock38_6c217765776402" data-cb-row-expanded="28" 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">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_race_6c217765776402LabelCell" data-cb-row-expanded="28" 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"><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></div>
<div class="cbFormFieldCell" data-cb-row-expanded="28" 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">
<div class="cbComboBoxContainer" style="position: relative;">
<div id="ComboBoxInsertRecordParticipant_race_6c217765776402">
<div class="ListData ListBox cbFormMultiSelect" tabindex="0" data-cb-name="MultiSelectListBox" style="width: 600px; min-width: 10px; height: 411px; background-color: rgb(255, 255, 255);">
<div class="Body" style="overflow-y: hidden;">
<div style="width: 100%;">
<div style="overflow-y: auto; height: 150px;">
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_race_6c217765776402_unchecked_0"><label for="InsertRecordParticipant_race_6c217765776402_unchecked_0" style="vertical-align: middle;">African American, Black, or African Diaspora</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_race_6c217765776402_unchecked_1"><label for="InsertRecordParticipant_race_6c217765776402_unchecked_1" style="vertical-align: middle;">American Indian or Alaska Native</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_race_6c217765776402_unchecked_2"><label for="InsertRecordParticipant_race_6c217765776402_unchecked_2" style="vertical-align: middle;">Asian or Asian American</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_race_6c217765776402_unchecked_3"><label for="InsertRecordParticipant_race_6c217765776402_unchecked_3" style="vertical-align: middle;">Hispanic or Latino/a/x/e</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_race_6c217765776402_unchecked_4"><label for="InsertRecordParticipant_race_6c217765776402_unchecked_4" style="vertical-align: middle;">Middle Eastern or North African</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_race_6c217765776402_unchecked_5"><label for="InsertRecordParticipant_race_6c217765776402_unchecked_5" style="vertical-align: middle;">Native Hawaiian or Pacific Islander</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_race_6c217765776402_unchecked_6"><label for="InsertRecordParticipant_race_6c217765776402_unchecked_6" style="vertical-align: middle;">White or Caucasian</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_race_6c217765776402_unchecked_7"><label for="InsertRecordParticipant_race_6c217765776402_unchecked_7" style="vertical-align: middle;">An identity not listed/self-identify:</label></div>
</div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="InsertRecordParticipant_race" id="InsertRecordParticipant_race_6c217765776402" value="">
</div>
</div>
<div class="cbFormFieldCell cbFormBlock39_6c217765776402" data-cb-row-expanded="29" 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"
style="display: none;"><input type="text" maxlength="255" name="InsertRecordParticipant_race_other" id="InsertRecordParticipant_race_other" value="" class="cbFormTextField" size="25" placeholder="Please describe your racial identity" title=""
style="display: none;"></div>
<div class="cbFormNestedTableContainer cbFormBlock40_6c217765776402" data-cb-row-expanded="30" data-cb-row-collapsed="30" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_sexual_identity_6c217765776402LabelCell" data-cb-row-expanded="30" data-cb-row-collapsed="30" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><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></div>
<div class="cbFormFieldCell" data-cb-row-expanded="30" data-cb-row-collapsed="30" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even">
<div class="cbComboBoxContainer" style="position: relative;">
<div id="ComboBoxInsertRecordParticipant_sexual_identity_6c217765776402">
<div class="ListData ListBox cbFormMultiSelect" tabindex="0" data-cb-name="MultiSelectListBox" style="width: 600px; min-width: 10px; height: 295px; background-color: rgb(255, 255, 255);">
<div class="Body" style="overflow-y: hidden;">
<div style="width: 100%;">
<div style="overflow-y: auto; height: 150px;">
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_0"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_0" style="vertical-align: middle;">Asexual</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_1"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_1" style="vertical-align: middle;">Bisexual</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_2"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_2" style="vertical-align: middle;">Gay</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_3"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_3" style="vertical-align: middle;">Heterosexual</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_4"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_4" style="vertical-align: middle;">Lesbian</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_5"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_5" style="vertical-align: middle;">Pansexual</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_6"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_6" style="vertical-align: middle;">Queer</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_7"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_7" style="vertical-align: middle;">Questioning</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_8"><label for="InsertRecordParticipant_sexual_identity_6c217765776402_unchecked_8" style="vertical-align: middle;">An identity not
listed/self-identify:</label></div>
</div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="InsertRecordParticipant_sexual_identity" id="InsertRecordParticipant_sexual_identity_6c217765776402" value="">
</div>
</div>
<div class="cbFormFieldCell cbFormBlock41_6c217765776402" data-cb-row-expanded="31" data-cb-row-collapsed="31" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"
style="display: none;"><input type="text" maxlength="255" name="InsertRecordParticipant_sexual_identity_oth" id="InsertRecordParticipant_sexual_identity_oth" value="" class="cbFormTextField" size="25"
placeholder="Please describe your sexual identity" title="" style="display: none;"></div>
<div class="cbFormNestedTableContainer cbFormBlock42_6c217765776402" data-cb-row-expanded="32" data-cb-row-collapsed="32" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_SMA_crim_6c217765776402LabelCell" data-cb-row-expanded="32" data-cb-row-collapsed="32" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label id="InsertRecordParticipant_SMA_crim_lbl_6c217765776402"><br><span
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>
<div class="cbFormFieldCell" data-cb-row-expanded="32" data-cb-row-collapsed="32" data-cb-alternate-semantic-row-desktop="Even" 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_SMA_crim_lbl_6c217765776402" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_SMA_crim"
id="InsertRecordParticipant_SMA_crim0_6c217765776402" value="Yes"><label for="InsertRecordParticipant_SMA_crim0_6c217765776402">Yes</label><br><input type="radio" name="InsertRecordParticipant_SMA_crim"
id="InsertRecordParticipant_SMA_crim1_6c217765776402" value="No"><label for="InsertRecordParticipant_SMA_crim1_6c217765776402">No</label><br><input type="radio" name="InsertRecordParticipant_SMA_crim"
id="InsertRecordParticipant_SMA_crim2_6c217765776402" value="Unsure"><label for="InsertRecordParticipant_SMA_crim2_6c217765776402">Unsure</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock43_6c217765776402" data-cb-row-expanded="33" data-cb-row-collapsed="33" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_SMA_safe_6c217765776402LabelCell" data-cb-row-expanded="33" data-cb-row-collapsed="33" data-cb-alternate-semantic-row-desktop="Odd"
data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label id="InsertRecordParticipant_SMA_safe_lbl_6c217765776402">
<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>
<div class="cbFormFieldCell" data-cb-row-expanded="33" data-cb-row-collapsed="33" data-cb-alternate-semantic-row-desktop="Odd" 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_SMA_safe_lbl_6c217765776402" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_SMA_safe"
id="InsertRecordParticipant_SMA_safe0_6c217765776402" value="Very Unsafe"><label for="InsertRecordParticipant_SMA_safe0_6c217765776402">Very Unsafe</label><br><input type="radio" name="InsertRecordParticipant_SMA_safe"
id="InsertRecordParticipant_SMA_safe1_6c217765776402" value="Somewhat Unsafe"><label for="InsertRecordParticipant_SMA_safe1_6c217765776402">Somewhat Unsafe</label><br><input type="radio" name="InsertRecordParticipant_SMA_safe"
id="InsertRecordParticipant_SMA_safe2_6c217765776402" value="Neither Unsafe nor Safe"><label for="InsertRecordParticipant_SMA_safe2_6c217765776402">Neither Unsafe nor Safe</label><br><input type="radio"
name="InsertRecordParticipant_SMA_safe" id="InsertRecordParticipant_SMA_safe3_6c217765776402" value="Somewhat Safe"><label for="InsertRecordParticipant_SMA_safe3_6c217765776402">Somewhat Safe</label><br><input type="radio"
name="InsertRecordParticipant_SMA_safe" id="InsertRecordParticipant_SMA_safe4_6c217765776402" value="Very Safe"><label for="InsertRecordParticipant_SMA_safe4_6c217765776402">Very Safe</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock44_6c217765776402" data-cb-row-expanded="34" 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">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordHear_about_webinar_6c217765776402LabelCell" data-cb-row-expanded="34" 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 style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">How did you hear about this webinar?</span></div>
<div class="cbFormFieldCell" data-cb-row-expanded="34" 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">
<div class="cbComboBoxContainer" style="position: relative;">
<div id="ComboBoxInsertRecordHear_about_webinar_6c217765776402">
<div class="ListData ListBox cbFormMultiSelect" tabindex="0" data-cb-name="MultiSelectListBox" style="width: 700px; min-width: 10px; height: 295px; background-color: rgb(255, 255, 255);">
<div class="Body" style="overflow-y: hidden;">
<div style="width: 100%;">
<div style="overflow-y: auto; height: 150px;">
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_0"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_0" style="vertical-align: middle;">Colleague</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_1"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_1" style="vertical-align: middle;">Facebook</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_2"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_2" style="vertical-align: middle;">Friend</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_3"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_3" style="vertical-align: middle;">Instagram</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_4"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_4" style="vertical-align: middle;">LinkedIn</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_5"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_5" style="vertical-align: middle;">Other Website</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_6"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_6" style="vertical-align: middle;">Provide Email</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_7"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_7" style="vertical-align: middle;">Provide Website</label></div>
<div class="cbFormMultiSelectText" style="outline: none; white-space: nowrap; overflow: hidden;"><input type="checkbox" style="outline: none; margin-left: 0px; margin-right: 6px; vertical-align: middle;"
id="InsertRecordHear_about_webinar_6c217765776402_unchecked_8"><label for="InsertRecordHear_about_webinar_6c217765776402_unchecked_8" style="vertical-align: middle;">Twitter</label></div>
</div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="InsertRecordHear_about_webinar" id="InsertRecordHear_about_webinar_6c217765776402" value="">
</div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock45_6c217765776402"><input type="hidden" value="" id="HTMLBlock6c46858f965936d918373d" name="HTMLBlock6c46858f965936d918373d">
<div class="cbFormNestedTableContainer cbFormBlock46_6c217765776402" data-cb-row-expanded="36" data-cb-row-collapsed="36" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_burnout_6c217765776402LabelCell" data-cb-row-expanded="36" data-cb-row-collapsed="36" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label id="InsertRecordParticipant_burnout_lbl_6c217765776402"></label></div>
</div>
<table style="width: 800px !important;">
<tbody>
<tr>
<td style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Overall, based on your definition of burnout, how would you rate your level of burnout?<div class="cbFormFieldCell" data-cb-row-expanded="36"
data-cb-row-collapsed="36" data-cb-alternate-semantic-row-desktop="Even" 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_burnout_lbl_6c217765776402" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_burnout"
id="InsertRecordParticipant_burnout0_6c217765776402" value="1 - no symptoms"><label for="InsertRecordParticipant_burnout0_6c217765776402">I enjoy my work. I have no symptoms of burnout. </label><br><input type="radio"
name="InsertRecordParticipant_burnout" id="InsertRecordParticipant_burnout1_6c217765776402" value="2 - some symptoms"><label for="InsertRecordParticipant_burnout1_6c217765776402">Occasionally I am under stress, and I don't
always have as much energy as I once did, but I don't feel burned out. </label><br><input type="radio" name="InsertRecordParticipant_burnout" id="InsertRecordParticipant_burnout2_6c217765776402" value="3 - burning out"><label
for="InsertRecordParticipant_burnout2_6c217765776402">I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. </label><br><input type="radio"
name="InsertRecordParticipant_burnout" id="InsertRecordParticipant_burnout3_6c217765776402" value="4 - burnt out"><label for="InsertRecordParticipant_burnout3_6c217765776402">The symptoms of burnout that I am experiencing
won't go away. I think about frustration at work a lot. </label><br><input type="radio" name="InsertRecordParticipant_burnout" id="InsertRecordParticipant_burnout4_6c217765776402" value="5 - completely burnt out"><label
for="InsertRecordParticipant_burnout4_6c217765776402"><span style="width: 800px">I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of
help. </span></label><br></span></fieldset>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock47_6c217765776402"><input type="hidden" value="" id="HTMLBlock6c46858f9610ba0696bee4" name="HTMLBlock6c46858f9610ba0696bee4"></div>
</td>
</tr>
</tbody>
</table>
</div>
<div class="cbSubmitButtonContainer cbFormBlock48_6c217765776402"><input type="submit" name="Submit" id="Submit_6c217765776402" value="Finish" class="cbSubmitButton"></div>
</section>
</div>
</form>Text Content
Registration: 5/29/2024 | 11:00:00 AM EST | 3 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* Email* Verify Email* Phone Number: Zip Code* City State Job title Organization (Spell out all acronyms) Do you work in any of the following systems of care? (Mark all that apply) Family Planning Health Care Intimate Partner Violence Sexual Assault Education HIV Mental and Behavioral Health Native American/Tribal Pharmacy Abortion Fund Public Health Law/Policy Substance Use Disorder Other Medication Assisted Treatment (Methadone/Suboxone/Other) Harm Reduction 12 Step Addiction Treatment How would you describe your current role? (Mark all that apply) I work directly with clients/patients Administration or Support Leadership (supervisor, director, executive, etc.) Board Member Social Worker Mental or Behavioral Health Provider Case Worker or Case Manager Client Educator or Client Advocate Physician or Physician’s Assistant Nurse (RN, LPN, NP, midwife, etc.) Medical Assistant (MA) Educator/Education Affiliated Public Health Worker Pharmacist Attorney Other How would you describe your client population? (select all that apply) Mostly rural Mostly lower income At least half people who can get pregnant At least half Black, Indigenous, and People of Color 20% or more non-native English speaking 10% or more LGBQ (Lesbian, Gay, Bisexual, or Queer) 5% or more transgender or gender expansive 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) Agender Gender Non-Conforming Genderqueer Man Non-binary Transgender Woman An identity not listed/self-identify: How would you describe your race and ethnicity? (mark all that apply) African American, Black, or African Diaspora American Indian or Alaska Native Asian or Asian American Hispanic or Latino/a/x/e Middle Eastern or North African Native Hawaiian or Pacific Islander White or Caucasian An identity not listed/self-identify: How do you describe your sexual identity? [mark all that apply] Asexual Bisexual Gay Heterosexual Lesbian Pansexual Queer Questioning An identity not listed/self-identify: 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? Colleague Facebook Friend Instagram LinkedIn Other Website Provide Email Provide Website Twitter Overall, based on your definition of burnout, how would you rate your level of burnout? I enjoy my work. I have no symptoms of burnout. Occasionally I am under stress, and I don't always have as much energy as I once did, but I don't feel burned out. I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. The symptoms of burnout that I am experiencing won't go away. I think about frustration at work a lot. I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help.