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DE - Quality Insights Maternal Health Intake for Community Health Workers
*
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):
*
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)
Monday
Tuesday
Wednesday
Thursday
Friday
Afternoon (12:00 pm - 5:00 pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Evening (5:00 pm – 7:00 pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Anytime
Monday
Tuesday
Wednesday
Thursday
Friday
*
3.
Is it okay to leave a message when the Community Health Worker calls?
(Required.)
Yes
No
*
4.
How did you hear about us?
(Required.)
Email/distribution list
Community organization
Medical facility
Friend/family
Community event
Other (please specify):
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