c1hcm464.caspio.com
Open in
urlscan Pro
35.174.249.52
Public Scan
URL:
https://c1hcm464.caspio.com/dp/d2dbb000d5629d48846c46858f96?fid=RegGF8PM8&en=Q4%20Virtual%20Referrals%20Training&utm_source=...
Submission: On September 24 via manual from US — Scanned from US
Submission: On September 24 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
POST https://c1hcm464.caspio.com/dp/d2dbb000d5629d48846c46858f96?fid=RegGF8PM8&en=Q4+Virtual+Referrals+Training&utm_source=Provide+Programs&utm_campaign=abad483488-EMAIL_CAMPAIGN_2024_07_16_02_45_COPY_01&utm_medium=email&utm_term=0_-8065204422-%5bLIST_
<form method="post" id="caspioform"
action="https://c1hcm464.caspio.com/dp/d2dbb000d5629d48846c46858f96?fid=RegGF8PM8&en=Q4+Virtual+Referrals+Training&utm_source=Provide+Programs&utm_campaign=abad483488-EMAIL_CAMPAIGN_2024_07_16_02_45_COPY_01&utm_medium=email&utm_term=0_-8065204422-%5bLIST_"
style="margin: 0px;"><input type="hidden" name="cbUniqueFormId" id="cbUniqueFormId_5b33310a790d4f" value="_5b33310a790d4f"><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=RegGF8PM8&en=Q4+Virtual+Referrals+Training&utm_source=Provide+Programs&utm_campaign=abad483488-EMAIL_CAMPAIGN_2024_07_16_02_45_COPY_01&utm_medium=email&utm_term=0_-8065204422-%5bLIST_"><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_5b33310a790d4f" name="InsertRecordEvent_ID"><input type="hidden" id="InsertRecordEvent_Type_5b33310a790d4f" name="InsertRecordEvent_Type"><input type="hidden"
id="InsertRecordReg_Form_ID" name="InsertRecordReg_Form_ID" value="RegGF8PM8"><input type="hidden" id="InsertRecordEvent_Name" name="InsertRecordEvent_Name" value="Q4 Virtual Referrals Training"><input type="hidden"
id="cbParamVirtual1_5b33310a790d4f" name="cbParamVirtual1"><input type="hidden" id="cbParamVirtual3_5b33310a790d4f" name="cbParamVirtual3"><input type="hidden" id="cbParamVirtual5_5b33310a790d4f" name="cbParamVirtual5"><input type="hidden"
id="cbParamVirtual9_5b33310a790d4f" name="cbParamVirtual9"><input type="hidden" id="cbParamVirtual6_5b33310a790d4f" name="cbParamVirtual6"><input type="hidden" id="cbParamVirtual7_5b33310a790d4f" name="cbParamVirtual7"><input type="hidden"
id="cbParamVirtual8_5b33310a790d4f" name="cbParamVirtual8"><input type="hidden" id="cbParamVirtual10_5b33310a790d4f" name="cbParamVirtual10"><input type="hidden" id="InsertRecordWebinar_url_5b33310a790d4f" name="InsertRecordWebinar_url"><input
type="hidden" id="InsertRecordEvent_date_5b33310a790d4f" name="InsertRecordEvent_date"><input type="hidden" id="InsertRecordEnd_time_5b33310a790d4f" name="InsertRecordEnd_time"><input type="hidden"
id="InsertRecordEvent_Name_branded_5b33310a790d4f" name="InsertRecordEvent_Name_branded"><input type="hidden" id="InsertRecordEvent_description_5b33310a790d4f" name="InsertRecordEvent_description">
<div style="display: table;">
<section data-cb-name="cbTable" id="cbTable_5b33310a790d4f" class="cbFormSection_5b33310a790d4f">
<div class="cbHTMLBlockContainer cbFormData cbFormBlock1_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f96e49a0de7335b" name="HTMLBlock6c46858f96e49a0de7335b">
<div style="margin-left: 600px;"><img alt="Provide logo" src="https://providecare.org/wp-content/uploads/2024/06/provide_logo_notag.png" style="width: 310px; height: 119px;"></div>
</div>
<div class="cbFormFieldCell cbFormBlock2_5b33310a790d4f" 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_5b33310a790d4f" style="display: none;"> </span><input type="hidden" id="cbParamVirtual2_5b33310a790d4f" name="cbParamVirtual2">
<div class="cbFormData cbFormCalculatedField" style="display: inline-block;">
<div class="cbFormComputedFieldPreloader" style="transform: rotate(360deg); transition-duration: 1s; transition-timing-function: linear;"></div>
</div>
</div>
<div class="cbFormFieldCell cbFormBlock3_5b33310a790d4f" 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_5b33310a790d4f" style="display: none;"> </span><input type="hidden" id="cbParamVirtual4_5b33310a790d4f" name="cbParamVirtual4">
<div class="cbFormData cbFormCalculatedField" style="display: inline-block;">
<div class="cbFormComputedFieldPreloader" style="transform: rotate(360deg); transition-duration: 1s; transition-timing-function: linear;"></div>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock4_5b33310a790d4f" 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_5b33310a790d4f">
<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_5b33310a790d4f">
<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 class="cbFormBlock7_5b33310a790d4f">
<div class="cbFormLabelCell cbFormLabel" 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="InsertRecordPreferred_name"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">What name should we use?</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="InsertRecordPreferred_name" id="InsertRecordPreferred_name" value="" class="cbFormTextField" size="40" placeholder="If different from name written"></div>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock8_5b33310a790d4f" 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="cbFormBlock9_5b33310a790d4f">
<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="cbFormBlock10_5b33310a790d4f">
<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 cbFormBlock11_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f96b8379edb44e7" name="HTMLBlock6c46858f96b8379edb44e7"></div>
<div class="cbFormNestedTableContainer cbFormBlock12_5b33310a790d4f" 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="cbFormBlock13_5b33310a790d4f">
<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="cbFormBlock14_5b33310a790d4f">
<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_5b33310a790d4f"><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_5b33310a790d4f" value="" class="cbFormTextField" size="10" autocomplete="off"></div>
</div>
<div class="cbFormBlock15_5b33310a790d4f">
<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_5b33310a790d4f"><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_5b33310a790d4f" value="" class="cbFormTextField" size="27" autocomplete="off"></div>
</div>
<div class="cbFormBlock16_5b33310a790d4f">
<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_5b33310a790d4f"><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_5b33310a790d4f" value="" class="cbFormTextField" size="10" autocomplete="off"></div>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock17_5b33310a790d4f" 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="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="75"></div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock18_5b33310a790d4f" data-cb-row-expanded="9" data-cb-row-collapsed="9" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd"
data-cb-alternate-semantic-row-mobile="Odd">
<div class="cbFormBlock19_5b33310a790d4f">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="9" data-cb-row-collapsed="9" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_organization_5b33310a790d4f"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Organization </span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="9" data-cb-row-collapsed="9" 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_organization" id="InsertRecordParticipant_organization_5b33310a790d4f" value="" class="cbFormTextField" size="55" autocomplete="off" placeholder="Please spell out acronyms"></div>
</div>
<div class="cbFormBlock20_5b33310a790d4f">
<div class="cbFormLabelCell cbFormLabel" data-cb-row-expanded="9" data-cb-row-collapsed="9" data-cb-alternate-semantic-row-desktop="Odd" data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label
for="InsertRecordParticipant_org_satt_dept"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Department or Sattelite Location</span></label></div>
<div class="cbFormFieldCell" data-cb-row-expanded="9" data-cb-row-collapsed="9" 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_org_satt_dept" id="InsertRecordParticipant_org_satt_dept" value="" class="cbFormTextField" size="55"></div>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock21_5b33310a790d4f" 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="cbFormLabelCell cbFormLabel" 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"><label
for="InsertRecordParticipant_org_zip"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">What is the zipcode of the organization/agency you work for?</span></label></div>
<div class="cbFormFieldCell" 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"><input type="text"
maxlength="255" name="InsertRecordParticipant_org_zip" id="InsertRecordParticipant_org_zip" value="" class="cbFormTextField" size="25"></div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock22_5b33310a790d4f" 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">
<div class="cbFormLabelCell cbFormLabel" data-cb-cell-name="InsertRecordParticipant_org_rural_5b33310a790d4fLabelCell" 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"><label id="InsertRecordParticipant_org_rural_lbl_5b33310a790d4f"><span style="font-size: 18px; font-family:arial, sans-serif; font-weight: bold;">Is the
organization/agency for which you primarily work located in a rural area?</span></label></div>
<div class="cbFormFieldCell" 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">
<fieldset class="cbFormFieldSet"><span class="cbFormData" role="group" aria-labelledby="InsertRecordParticipant_org_rural_lbl_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_org_rural"
id="InsertRecordParticipant_org_rural0_5b33310a790d4f" value="Yes"><label for="InsertRecordParticipant_org_rural0_5b33310a790d4f">Yes </label><input type="radio" name="InsertRecordParticipant_org_rural"
id="InsertRecordParticipant_org_rural1_5b33310a790d4f" value="No"><label for="InsertRecordParticipant_org_rural1_5b33310a790d4f">No </label><input type="radio" name="InsertRecordParticipant_org_rural"
id="InsertRecordParticipant_org_rural2_5b33310a790d4f" value="Don't Know"><label for="InsertRecordParticipant_org_rural2_5b33310a790d4f">Don't Know</label></span></fieldset>
</div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock23_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f96cc2b2c3e4e67" name="HTMLBlock6c46858f96cc2b2c3e4e67"><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 cbFormBlock24_5b33310a790d4f" data-cb-row-expanded="13" data-cb-row-collapsed="13" 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_ABfund" id="InsertRecordSys_ABfund" value="Abortion Fund or Practical Support"> <label for="InsertRecordSys_ABfund">Abortion Fund or
Practical Support</label></span></div>
<div class="cbFormFieldCell cbFormBlock25_5b33310a790d4f" data-cb-row-expanded="13" data-cb-row-collapsed="14" 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_PublicHealth" id="InsertRecordSys_PublicHealth" value="Public Health"> <label
for="InsertRecordSys_PublicHealth">Public Health</label></span></div>
<div class="cbFormFieldCell cbFormBlock26_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f960f4e1403ba7b" name="HTMLBlock6c46858f960f4e1403ba7b"><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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f9669cfcaabaefe" name="HTMLBlock6c46858f9669cfcaabaefe">
<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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4fLabelCell" 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_5b33310a790d4f"><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_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordClient_Pop_Rural_percent"
id="InsertRecordClient_Pop_Rural_percent0_5b33310a790d4f" value="Less than 25%"><label for="InsertRecordClient_Pop_Rural_percent0_5b33310a790d4f">Less than 25% </label><input type="radio"
name="InsertRecordClient_Pop_Rural_percent" id="InsertRecordClient_Pop_Rural_percent1_5b33310a790d4f" value="25% - 50%"><label for="InsertRecordClient_Pop_Rural_percent1_5b33310a790d4f">25% - 50% </label><input type="radio"
name="InsertRecordClient_Pop_Rural_percent" id="InsertRecordClient_Pop_Rural_percent2_5b33310a790d4f" value="More than 50%"><label for="InsertRecordClient_Pop_Rural_percent2_5b33310a790d4f">More than 50% </label><input
type="radio" name="InsertRecordClient_Pop_Rural_percent" id="InsertRecordClient_Pop_Rural_percent3_5b33310a790d4f" value="Don't Know"><label for="InsertRecordClient_Pop_Rural_percent3_5b33310a790d4f">Don't Know</label></span>
</fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock70_5b33310a790d4f" 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_5b33310a790d4fLabelCell" 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_5b33310a790d4f"><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_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_Title_X"
id="InsertRecordParticipant_Title_X0_5b33310a790d4f" value="Yes"><label for="InsertRecordParticipant_Title_X0_5b33310a790d4f">Yes</label><br><input type="radio" name="InsertRecordParticipant_Title_X"
id="InsertRecordParticipant_Title_X1_5b33310a790d4f" value="No"><label for="InsertRecordParticipant_Title_X1_5b33310a790d4f">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock71_5b33310a790d4f" 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_5b33310a790d4fLabelCell" 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_5b33310a790d4f"><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_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_FQHC"
id="InsertRecordParticipant_FQHC0_5b33310a790d4f" value="Yes"><label for="InsertRecordParticipant_FQHC0_5b33310a790d4f">Yes</label><br><input type="radio" name="InsertRecordParticipant_FQHC"
id="InsertRecordParticipant_FQHC1_5b33310a790d4f" value="No"><label for="InsertRecordParticipant_FQHC1_5b33310a790d4f">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock72_5b33310a790d4f" 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_5b33310a790d4fLabelCell" 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_5b33310a790d4f"><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_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio"
name="InsertRecordParticipant_listserv_enroll" id="InsertRecordParticipant_listserv_enroll0_5b33310a790d4f" value="Yes"><label for="InsertRecordParticipant_listserv_enroll0_5b33310a790d4f">Yes</label><br><input type="radio"
name="InsertRecordParticipant_listserv_enroll" id="InsertRecordParticipant_listserv_enroll1_5b33310a790d4f" value="No"><label for="InsertRecordParticipant_listserv_enroll1_5b33310a790d4f">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock73_5b33310a790d4f" 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_5b33310a790d4fLabelCell" 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_5b33310a790d4f"><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_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordInterested_CEUs"
id="InsertRecordInterested_CEUs0_5b33310a790d4f" value="Yes"><label for="InsertRecordInterested_CEUs0_5b33310a790d4f">Yes</label><br><input type="radio" name="InsertRecordInterested_CEUs"
id="InsertRecordInterested_CEUs1_5b33310a790d4f" value="No"><label for="InsertRecordInterested_CEUs1_5b33310a790d4f">No</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock74_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4fLabelCell" 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_5b33310a790d4f">
<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_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_follow_up"
id="InsertRecordParticipant_follow_up0_5b33310a790d4f" value="Yes"><label for="InsertRecordParticipant_follow_up0_5b33310a790d4f">Yes</label><br><input type="radio" name="InsertRecordParticipant_follow_up"
id="InsertRecordParticipant_follow_up1_5b33310a790d4f" value="No"><label for="InsertRecordParticipant_follow_up1_5b33310a790d4f">No</label><br></span></fieldset>
</div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock77_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f960d383ffbcd4e" name="HTMLBlock6c46858f960d383ffbcd4e">
<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_5b33310a790d4f" 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_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f96cc769b73b5c5" name="HTMLBlock6c46858f96cc769b73b5c5"><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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f9601a2775023a2" name="HTMLBlock6c46858f9601a2775023a2">
<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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f" 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_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f96f36af77966dd" name="HTMLBlock6c46858f96f36af77966dd">
<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_5b33310a790d4f" 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>
<div class="cbFormFieldCell cbFormBlock101_5b33310a790d4f" data-cb-row-expanded="60" data-cb-row-collapsed="90" 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="InsertRecordSexID_lesb" id="InsertRecordSexID_lesb" value="Lesbian"> <label
for="InsertRecordSexID_lesb">Lesbian</label></span></div>
<div class="cbFormFieldCell cbFormBlock102_5b33310a790d4f" data-cb-row-expanded="61" data-cb-row-collapsed="91" 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="InsertRecordSexID_bi" id="InsertRecordSexID_bi" value="Bisexual"> <label
for="InsertRecordSexID_bi">Bisexual</label></span></div>
<div class="cbFormFieldCell cbFormBlock103_5b33310a790d4f" data-cb-row-expanded="61" data-cb-row-collapsed="92" 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="InsertRecordSexID_pan" id="InsertRecordSexID_pan" value="Pansexual"> <label
for="InsertRecordSexID_pan">Pansexual</label></span></div>
<div class="cbFormFieldCell cbFormBlock104_5b33310a790d4f" data-cb-row-expanded="62" data-cb-row-collapsed="93" 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_gay" id="InsertRecordSexID_gay" value="Gay"> <label
for="InsertRecordSexID_gay">Gay</label></span></div>
<div class="cbFormFieldCell cbFormBlock105_5b33310a790d4f" data-cb-row-expanded="62" data-cb-row-collapsed="94" 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="InsertRecordSexID_queer" id="InsertRecordSexID_queer" value="Queer"> <label
for="InsertRecordSexID_queer">Queer</label></span></div>
<div class="cbFormFieldCell cbFormBlock106_5b33310a790d4f" data-cb-row-expanded="63" data-cb-row-collapsed="95" 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="InsertRecordSexID_hetero" id="InsertRecordSexID_hetero" value="Heterosexual"> <label
for="InsertRecordSexID_hetero">Heterosexual</label></span></div>
<div class="cbFormFieldCell cbFormBlock107_5b33310a790d4f" data-cb-row-expanded="63" data-cb-row-collapsed="96" 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="InsertRecordSexID_other" id="InsertRecordSexID_other" value="Other"> <label
for="InsertRecordSexID_other">Another sexual identity not listed</label></span></div>
<div class="cbFormFieldCell cbFormBlock108_5b33310a790d4f" data-cb-row-expanded="64" data-cb-row-collapsed="97" 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_sexual_identity_oth" id="InsertRecordParticipant_sexual_identity_oth" value="" class="cbFormTextField"
size="30" placeholder="Please describe your sexual identity" title="" style="display: none;"></div>
<div class="cbFormNestedTableContainer cbFormBlock109_5b33310a790d4f" data-cb-row-expanded="65" data-cb-row-collapsed="98" 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_SMA_crim_5b33310a790d4fLabelCell" data-cb-row-expanded="65" data-cb-row-collapsed="98" data-cb-alternate-semantic-row-desktop="Odd"
data-cb-alternate-semantic-row-tablet="Even" data-cb-alternate-semantic-row-mobile="Even"><label id="InsertRecordParticipant_SMA_crim_lbl_5b33310a790d4f"><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="65" data-cb-row-collapsed="98" 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_SMA_crim_lbl_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_SMA_crim"
id="InsertRecordParticipant_SMA_crim0_5b33310a790d4f" value="Yes"><label for="InsertRecordParticipant_SMA_crim0_5b33310a790d4f">Yes</label><br><input type="radio" name="InsertRecordParticipant_SMA_crim"
id="InsertRecordParticipant_SMA_crim1_5b33310a790d4f" value="No"><label for="InsertRecordParticipant_SMA_crim1_5b33310a790d4f">No</label><br><input type="radio" name="InsertRecordParticipant_SMA_crim"
id="InsertRecordParticipant_SMA_crim2_5b33310a790d4f" value="Unsure"><label for="InsertRecordParticipant_SMA_crim2_5b33310a790d4f">Unsure</label><br></span></fieldset>
</div>
</div>
<div class="cbFormNestedTableContainer cbFormBlock110_5b33310a790d4f" data-cb-row-expanded="66" data-cb-row-collapsed="99" 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_SMA_safe_5b33310a790d4fLabelCell" data-cb-row-expanded="66" data-cb-row-collapsed="99" data-cb-alternate-semantic-row-desktop="Even"
data-cb-alternate-semantic-row-tablet="Odd" data-cb-alternate-semantic-row-mobile="Odd"><label id="InsertRecordParticipant_SMA_safe_lbl_5b33310a790d4f">
<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="66" data-cb-row-collapsed="99" 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_SMA_safe_lbl_5b33310a790d4f" data-cb-name="cbFormDataRadios"><input type="radio" name="InsertRecordParticipant_SMA_safe"
id="InsertRecordParticipant_SMA_safe0_5b33310a790d4f" value="Very Unsafe"><label for="InsertRecordParticipant_SMA_safe0_5b33310a790d4f">Very Unsafe</label><br><input type="radio" name="InsertRecordParticipant_SMA_safe"
id="InsertRecordParticipant_SMA_safe1_5b33310a790d4f" value="Somewhat Unsafe"><label for="InsertRecordParticipant_SMA_safe1_5b33310a790d4f">Somewhat Unsafe</label><br><input type="radio" name="InsertRecordParticipant_SMA_safe"
id="InsertRecordParticipant_SMA_safe2_5b33310a790d4f" value="Neither Unsafe nor Safe"><label for="InsertRecordParticipant_SMA_safe2_5b33310a790d4f">Neither Unsafe nor Safe</label><br><input type="radio"
name="InsertRecordParticipant_SMA_safe" id="InsertRecordParticipant_SMA_safe3_5b33310a790d4f" value="Somewhat Safe"><label for="InsertRecordParticipant_SMA_safe3_5b33310a790d4f">Somewhat Safe</label><br><input type="radio"
name="InsertRecordParticipant_SMA_safe" id="InsertRecordParticipant_SMA_safe4_5b33310a790d4f" value="Very Safe"><label for="InsertRecordParticipant_SMA_safe4_5b33310a790d4f">Very Safe</label><br></span></fieldset>
</div>
</div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock111_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f96acb58eae3411" name="HTMLBlock6c46858f96acb58eae3411"><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 cbFormBlock112_5b33310a790d4f" data-cb-row-expanded="68" data-cb-row-collapsed="101" 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="InsertRecordHearWeb_Prov_email" id="InsertRecordHearWeb_Prov_email" value="Provide Email"> <label
for="InsertRecordHearWeb_Prov_email">Provide Email</label></span></div>
<div class="cbFormFieldCell cbFormBlock113_5b33310a790d4f" data-cb-row-expanded="68" data-cb-row-collapsed="102" 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="InsertRecordHearWeb_Prov_insta" id="InsertRecordHearWeb_Prov_insta" value="Instagram"> <label
for="InsertRecordHearWeb_Prov_insta">Instagram</label></span></div>
<div class="cbFormFieldCell cbFormBlock114_5b33310a790d4f" data-cb-row-expanded="69" data-cb-row-collapsed="103" 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="InsertRecordHearWeb_Prov_web" id="InsertRecordHearWeb_Prov_web" value="Provide Website"> <label
for="InsertRecordHearWeb_Prov_web">Provide Website</label></span></div>
<div class="cbFormFieldCell cbFormBlock115_5b33310a790d4f" data-cb-row-expanded="69" data-cb-row-collapsed="104" 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="InsertRecordHearWeb_inperson" id="InsertRecordHearWeb_inperson" value="In-Person Outreach"> <label
for="InsertRecordHearWeb_inperson">In-Person Outreach by Provide Staff</label></span></div>
<div class="cbFormFieldCell cbFormBlock116_5b33310a790d4f" data-cb-row-expanded="70" data-cb-row-collapsed="105" 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="InsertRecordHearWeb_Prov_coll" id="InsertRecordHearWeb_Prov_coll" value="Colleague"> <label
for="InsertRecordHearWeb_Prov_coll">Colleague</label></span></div>
<div class="cbFormFieldCell cbFormBlock117_5b33310a790d4f" data-cb-row-expanded="70" data-cb-row-collapsed="106" 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="InsertRecordHearWeb_conference" id="InsertRecordHearWeb_conference" value="Conference"> <label
for="InsertRecordHearWeb_conference">Conference </label></span></div>
<div class="cbFormFieldCell cbFormBlock118_5b33310a790d4f" data-cb-row-expanded="71" data-cb-row-collapsed="107" 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="InsertRecordHearWeb_Prov_friend" id="InsertRecordHearWeb_Prov_friend" value="Friend"> <label
for="InsertRecordHearWeb_Prov_friend">Friend</label></span></div>
<div class="cbFormFieldCell cbFormBlock119_5b33310a790d4f" data-cb-row-expanded="71" data-cb-row-collapsed="108" 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="InsertRecordHearWeb_Prov_oth_web" id="InsertRecordHearWeb_Prov_oth_web" value="Other Website"> <label
for="InsertRecordHearWeb_Prov_oth_web">Other Website</label></span></div>
<div class="cbFormFieldCell cbFormBlock120_5b33310a790d4f" data-cb-row-expanded="72" data-cb-row-collapsed="109" 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="InsertRecordHearWeb_Prov_fb" id="InsertRecordHearWeb_Prov_fb" value="Facebook"> <label
for="InsertRecordHearWeb_Prov_fb">Facebook</label></span></div>
<div data-display-order="19" class="cbFormLabelCell cbFormLabel cbFormBlock121_5b33310a790d4f" data-cb-row-expanded="72" data-cb-row-collapsed="110" data-cb-alternate-semantic-row-desktop="Even" data-cb-alternate-semantic-row-tablet="Even"
data-cb-alternate-semantic-row-mobile="Even"></div>
<div class="cbFormFieldCell cbFormBlock122_5b33310a790d4f" data-cb-row-expanded="73" data-cb-row-collapsed="111" 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="InsertRecordHearWeb_inperson_who" id="InsertRecordHearWeb_inperson_who" value="" class="cbFormTextField" size="40"
placeholder="What staff shared the training with you? (leave blank if unsure)" title="What staff shared the training with you? (leave blank if unsure)" style="display: none;"></div>
<div class="cbFormFieldCell cbFormBlock123_5b33310a790d4f" data-cb-row-expanded="74" data-cb-row-collapsed="112" 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="InsertRecordHearWeb_conference_where" id="InsertRecordHearWeb_conference_where" value="" class="cbFormTextField" size="30"
placeholder="What conference? (specify):" title="What conference? (specify):" style="display: none;"></div>
<div class="cbFormFieldCell cbFormBlock124_5b33310a790d4f" data-cb-row-expanded="75" data-cb-row-collapsed="113" 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="InsertRecordHear_Website_Other" id="InsertRecordHear_Website_Other" value="" class="cbFormTextField" size="30"
placeholder="Which other Website?" title="Other Website (specify):" style="display: none;"></div>
<div class="cbHTMLBlockContainer cbFormData cbFormBlock125_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f9620e367557137" name="HTMLBlock6c46858f9620e367557137">
<div class="cbHTMLBlockContainer cbFormData cbFormBlock126_5b33310a790d4f"><input type="hidden" value="" id="HTMLBlock6c46858f962460b9d3d862" name="HTMLBlock6c46858f962460b9d3d862">
</div>
<table style="width: 800px !important;">
<tbody>
<tr></tr>
</tbody>
</table>
</div>
<div class="cbSubmitButtonContainer cbFormBlock127_5b33310a790d4f"><input type="submit" name="Submit" id="Submit_5b33310a790d4f" value="Finish" class="cbSubmitButton"></div>
</section>
</div>
</form>Text Content
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