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* 1. Your Name

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* 2. Your Email Address

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* 3. Your Phone Number

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* 4. Are you a:

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* 5. Your story contains the following topics (check all that apply):

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* 6. Share your story:

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* 7. Do you consent to us sharing your story?

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* 8. Do you have photos or videos to share along with your story?

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* 9. Have you contacted a local official or policymaker about your story?

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* 10. If you answered yes, to contacting a local official or policymaker about your story, please name the person you contacted and what their response was:

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* 11. If you believe additional action needs to be taken by your local official or legislator, what would that be?

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* 12. Other than becoming sick with COVID-19, what else might you be worried about? (check all that apply)

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* 13. Have you participated in the 'Coffee with Katheryne' sessions hosted by MODDC?

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* 14. (Optional) What is your race?

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* 15. (Optional) Do you live in an urban or rural area?

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* 16. (Optional) What is your gender?

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