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PBWHA Youth Needs Assessment (Ages 12–18)
Estimated time: 10–15 minutes
All responses are private. Your feedback helps PBWHA design programs that support youth health, well-being, and community.
1.
What is your email address?
Demographic Information
*
2.
How old are you?
(Required.)
*
3.
Gender identity (select one):
(Required.)
Woman/Girl
Man/Boy
Trans Man
Trans Woman
Non-binary/Non-conforming
Prefer not to respond
Prefer to Self Identify
*
4.
Race / Ethnicity (check all that apply):
(Required.)
Black / African American
Hispanic / Latino / Latinx
Asian / Asian American
Native American / Alaska Native
Native Hawaiian / Pacific Islander
Middle Eastern / North African
White
More than one race
Prefer not to say
Other (please specify)
*
5.
ZIP code:
(Required.)
