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* 1. First Name:

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* 2. Last Name:

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* 3. Title/Position:

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* 4. Organization Name:

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* 5. Your Primary Profession:

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* 7. Preferred Email Address:

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* 8. Preferred Phone Number:

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* 9. What is your race/ethnicity? (select all that apply)

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* 10. What is your gender?

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* 11. Please describe your interest in participating in AI Health.

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* 12. What are the demographics of the African immigrant patients that you serve (i.e. immigration status, country of origin, length of time in the US, etc)?

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* 13. What challenges are you experiencing in engaging African immigrants into HIV services? If possible, please give a specific example.

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* 14. What successes are you experiencing in engaging African immigrants into HIV services? If possible, please give a specific example.

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* 15. Do you currently have at least one case that you can share with peers?

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