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Illinois Oral Health Plan V Pre-Registration Survey

Thank you in advance for your interest in attending one of the Illinois Oral Health Plan (IOHP) planning meetings. The purpose of the information collected within this survey is to gather basic participant information for name tag creation, etc. Each attendee must be at least 18 years old and live in Illinois. We anticipate this survey will take approximately 3 - 5 minutes to complete.
1.Name(Required.)
2.Please list your credentials (if any). Meeting attendees will receive nametags upon arrival.
3.Email address(Required.)
4.Please select the primary perspective/role you bring to the IOHP planning process.(Required.)
5.Please indicate your organization or type of affiliation.(Required.)
6.Please provide the 5-digit zip code of your primary practice, organization, or community you represent.(Required.)
7.How did you hear about this event?(Required.)