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Early Childhood Committee Questionnaire
1.
What is your full name?
2.
What are your credentials?
3.
What is your preferred email address?
4.
What type of practice do you work at?
Residency program
Solo practice
Group practice
Hospital or health care system
Academic institution
Other (please specify)
5.
What is your position at the practice?
6.
Are you a member of the national AAP?
Yes
No
7.
If you are involved in any national AAP Councils or Sections, please list them below:
8.
Are you a part of the PA Chapter, AAP? (Please note that chapter membership is required for committee members.)
Yes
No
9.
If you are a member of any other PA AAP committees, please list them below:
10.
Gender: How do you identify?
Man
Non-binary
Woman
Prefer not to say
Prefer to self-identify:
11.
What is your ethnicity?
White, non-Hispanic
Black, non-Hispanic
Latino or Hispanic
Asian or Asian American
Native American
Prefer not to say
Prefer to self-identify:
12.
What is the city and zip code of your practice?