Post-Test: Confronting the Public Health Threat of Racism: A Social Work Response Survey

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* 1. What is your name?

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* 2. What is your email address?

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* 3. What is your profession / discipline?

Behavioral Health – Social Work

Behavioral Health – Psychology

Behavioral Health – Addiction Counseling

Dentistry

Medicine

Nursing

Paraprofessional

Public Health

Physician Assistant

Student – Graduate Studies

Student – Paraprofessional

Student – Undergraduate Studies

Other (please specify)

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* 4. What is your highest degree?

Health Sciences - PA

Health Sciences - MD

Health Sciences - DO

Nursing - RN

Nursing - BSN

Nursing - MSN

Psychology - BA

Psychology - MA (Counseling Psychology)

Psychology - Psy. D.

Psychology - Ph. D.

Social Work - BSW

Social Work - MSW

Social Work - DSW

Social Work - Ph. D.

Other (please specify)

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* 5. Please fill out your professional license information:

Type:

State:

Number:

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* 6. Are you employed by any of the following IBHC Community Partners? Please check all that apply.

Baystate Medical Center Partial Hospitalization Program

Baystate Medical Center Family Advocacy Center

Brien Center

Caring Health Center

CHD Outpatient/DBT Program

Clinical & Support Options, Inc.

Family Health Center of Worcester

Friends of the Homeless

Mercy Life

Mass Center for Integrated Primary Care

New England Hospice

Providence Behavioral Health Hospital

Swift River

West Central & Family Counseling

Gandara Center

Edward M Kennedy Community Health Center

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* 7. If not employed by any of the IBHC partners listed in Question #6, please list the name of your employer.

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* 8. What is the address of your agency / employer? (Please include zip code)

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* 9. Do we have your permission to let your employer know that you participated in this learning module?

Yes

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* 10. Please select the populations served by your agency, choose all that apply:

Adolescents

Children

Chronically ill

College students

Homeless individuals

Individuals with HIV / AIDS

Individuals with mental illness or substance use disorders

Lesbian/Gay/Bisexual/Transgender

Low income persons / families

Migrant workers

Pregnant women and infants

Refugee adults

People with disabilities

Undocumented immigrants

Unemployed

Returning war veterans (Iraq or Afghanistan)

Veterans

Transitional age youth (16-25 years)

Uninsured / underinsured persons / families

Tribal populations

Victims of abuse or trauma

None of the above

Other (please specify)