Healthy Start: Informed and Empowered

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1. Name (Required.)

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2. Age (Required.)

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3. Email (Required.)

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4. Contact number (Required.)

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5. Address Zip Code (Required.)

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6. Agency Name (type n/a if none)

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7. Agency Address (type N/A if not applicable)

Address Line 1

Address Line 2

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8. Are you a Community Health Worker/Doula/PNCC? (Required.)

Yes

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9. Which webinar date/s are you attending? (you may select multiple) (Required.)

Tuesday, July 21st, 2026 12:00-1:00 PM

Tuesday, July 28th, 2026 12:00-1:00 PM

Tuesday, August 4th, 2026 12:00-1:00 PM

Tuesday, August 18th, 2026 12:00-1:00 PM

Tuesday, August 25th, 2026 12:00-1:00 PM

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10. Are you in your reproductive years? "Reproductive years" generally refer to the ages when a person is capable of having children. (Required.)

Yes

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11. Are you currently...? (Required.)

Preconceptive (No prior pregnancies, no prior children, not pregnant)

Pregnant or expecting

Postpartum (delivered less than 6 months prior to today)

Parenting an infant less than 6 months of age

Parenting a child 6-11 months of age

Parenting a child 12-18 months of age

None of the above

Decline to answer

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12. How do you currently describe yourself? (Required.)

Male

Female

Transgender Woman/ Transgender Female/ Transfeminine

Transgender Man/ Transgender Male/ Transmasculine

Decline to answer

I use a different term (please specify)

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13. What sex were you assigned at birth, on your original birth certificate? (Required.)

Female

Male

Decline to answer

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14. Are you of Hispanic, Latino/a, or Spanish origin?
(select all that apply) (Required.)

No, not of Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, Another Hispanic, Latino/a, or Spanish origin

Decline to answer

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15. What is your race?
(select all that apply) (Required.)

White

Black or African American

American Indian or Alaska Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Decline to answer

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16. Do you speak a language other than English at home?
(Select one) (Required.)

Decline to answer

Yes (please specify)

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17. How well do you speak English? (Required.)

Very well

Well

Not well

Not at all

Decline to answer

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18. What is the highest grade or level of school that you have completed? (Required.)

No formal schooling

8th grade or less

Some high school (Grades 9, 10, 11, and 12)

High school diploma (Completed 12th grade)

G.E.D.

Some college or 2-year degree

Technical or trade school

Bachelor's degree

Graduate or professional school

Decline to answer

Healthy Start: Informed and Empowered

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* 1. Name (Required.)

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* 2. Age (Required.)

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* 3. Email (Required.)

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* 4. Contact number (Required.)

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* 5. Address Zip Code (Required.)

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* 6. Agency Name (type n/a if none)

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* 7. Agency Address (type N/A if not applicable)

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* 8. Are you a Community Health Worker/Doula/PNCC? (Required.)

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* 9. Which webinar date/s are you attending? (you may select multiple) (Required.)

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* 10. Are you in your reproductive years? "Reproductive years" generally refer to the ages when a person is capable of having children. (Required.)

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* 11. Are you currently...? (Required.)

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* 12. How do you currently describe yourself? (Required.)

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* 13. What sex were you assigned at birth, on your original birth certificate? (Required.)

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* 14. Are you of Hispanic, Latino/a, or Spanish origin? (select all that apply) (Required.)

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* 15. What is your race? (select all that apply) (Required.)

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* 16. Do you speak a language other than English at home?(Select one) (Required.)

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* 17. How well do you speak English? (Required.)

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* 18. What is the highest grade or level of school that you have completed? (Required.)

1. Name (Required.)

2. Age (Required.)

3. Email (Required.)

4. Contact number (Required.)

5. Address Zip Code (Required.)

6. Agency Name (type n/a if none)

7. Agency Address (type N/A if not applicable)

8. Are you a Community Health Worker/Doula/PNCC? (Required.)

9. Which webinar date/s are you attending? (you may select multiple) (Required.)

10. Are you in your reproductive years? "Reproductive years" generally refer to the ages when a person is capable of having children. (Required.)

11. Are you currently...? (Required.)

12. How do you currently describe yourself? (Required.)

13. What sex were you assigned at birth, on your original birth certificate? (Required.)

14. Are you of Hispanic, Latino/a, or Spanish origin?
(select all that apply) (Required.)

15. What is your race?
(select all that apply) (Required.)

16. Do you speak a language other than English at home?
(Select one) (Required.)

17. How well do you speak English? (Required.)

18. What is the highest grade or level of school that you have completed? (Required.)