All information in this application will be private and confidential. It will only be used for the Community Research Advisory Board (CRAB) Application process. Answering Questions 8 and below is optional; you can choose which questions you would like to answer. Your answers will help us choose a diverse CRAB. If you have any questions regarding the CRAB or the application, please email InstituteResearch@equitashealth.com. 

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* 1. Names You Use or Go By

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* 2. Gender Pronouns You Use

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* 3. Address

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* 4. May we mention Equitas Health when calling?

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* 5. Best Time to Call

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* 6. Employer (if applicable)

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* 7. Job Title (if applicable)

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* 8. Age

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* 9. Do you identify as a member of the Trans and/or Non-Binary community?

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* 10. Gender (Check all that apply):

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* 11. Do you consider yourself to be intersex?

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* 12. Sexual and Romantic Attraction (check all that apply)

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* 13. Race (check all that apply)

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* 14. Ethnicity (check all that apply)

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* 15. Do you self-define yourself as having a disability?

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* 16. Do you require any accommodations to participate in CRAB?

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* 17. If you have been a member of any boards, organizations, or groups, please list these below. Also, please include how long you were a part of these groups and what you learned from those experiences.

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* 18. Everyone has a special set of experiences and understanding. What unique perspectives or life experiences would you bring to the CRAB?

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* 19. What community work have you done (i.e. neighborhood groups, volunteering, church groups, advocacy or political groups)?

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* 20. What would you like to gain /learn from being a CRAB member?

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