DE - Quality Insights Maternal Health Intake for Community Health Workers

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1. Please provide the following information: (Required.)

Name:

Preferred Phone #:

Email Address:

Zip Code:

Sex (Male or Female):

Preferred pronoun (she/her, he/him, they/them):

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2. When is the best time to contact you Monday through Friday? (Check all that apply.) (Required.)

	Monday	Tuesday	Wednesday	Thursday	Friday
Morning (8:00 am - 12:00 pm)	Morning (8:00 am - 12:00 pm) Monday	Morning (8:00 am - 12:00 pm) Tuesday	Morning (8:00 am - 12:00 pm) Wednesday	Morning (8:00 am - 12:00 pm) Thursday	Morning (8:00 am - 12:00 pm) Friday
Afternoon (12:00 pm - 5:00 pm)	Afternoon (12:00 pm - 5:00 pm) Monday	Afternoon (12:00 pm - 5:00 pm) Tuesday	Afternoon (12:00 pm - 5:00 pm) Wednesday	Afternoon (12:00 pm - 5:00 pm) Thursday	Afternoon (12:00 pm - 5:00 pm) Friday
Evening (5:00 pm – 7:00 pm)	Evening (5:00 pm – 7:00 pm) Monday	Evening (5:00 pm – 7:00 pm) Tuesday	Evening (5:00 pm – 7:00 pm) Wednesday	Evening (5:00 pm – 7:00 pm) Thursday	Evening (5:00 pm – 7:00 pm) Friday
Anytime	Anytime Monday	Anytime Tuesday	Anytime Wednesday	Anytime Thursday	Anytime Friday

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3. Is it okay to leave a message when the Community Health Worker calls? (Required.)

Yes

No

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4. How did you hear about us? (Required.)

Email/distribution list

Community organization

Medical facility

Friend/family

Community event

Other (please specify):