Remote Maternal Health Intake Survey Question Title * 1. Please provide the following information: Name: Preferred phone #: Preferred email address: Question Title * 2. Is it okay to leave a message when the Community Health Worker calls? Yes No Question Title * 3. Please indicate the best days/times to contact you Monday through Friday. (Please select all that apply.) Monday Tuesday Wednesday Thursday Friday Morning (8:00 am to 12:00 pm) Morning (8:00 am to 12:00 pm) Monday Morning (8:00 am to 12:00 pm) Tuesday Morning (8:00 am to 12:00 pm) Wednesday Morning (8:00 am to 12:00 pm) Thursday Morning (8:00 am to 12:00 pm) Friday Afternoon (12:00 pm to 5:00 pm) Afternoon (12:00 pm to 5:00 pm) Monday Afternoon (12:00 pm to 5:00 pm) Tuesday Afternoon (12:00 pm to 5:00 pm) Wednesday Afternoon (12:00 pm to 5:00 pm) Thursday Afternoon (12:00 pm to 5:00 pm) Friday Evening (5:00 pm to 7:00 pm) Evening (5:00 pm to 7:00 pm) Monday Evening (5:00 pm to 7:00 pm) Tuesday Evening (5:00 pm to 7:00 pm) Wednesday Evening (5:00 pm to 7:00 pm) Thursday Evening (5:00 pm to 7:00 pm) Friday Anytime Anytime Monday Anytime Tuesday Anytime Wednesday Anytime Thursday Anytime Friday Question Title * 4. How did you hear about us? Email/Distribution List Community Organization Medical Facility Friend/Family Other (please specify): Question Title * 5. Do you have specific needs that you would like assistance with? (Please select all that apply.) Employment Food Housing Income Legal Mental Health Medical Substance Abuse Transportation Insurance Victimization None Other (please specify): Question Title * 6. What is your preferred language? English Spanish Other (please specify): Question Title * 7. Are you completing this survey on behalf of someone else? Yes No Next
