Toxic: A Black Woman's Story Registration Survey

Please complete this short pre-registration survey.

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* 1. Name

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* 2. Role

Malcolm X Student

Healthcare Provider / Clinician

Administrator

Other (please specify)

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* 3. Employer

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* 4. Email

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* 5. Age

16-24

25-34

35-49

50 or over

Prefer not to say

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* 6. Gender

Male

Female

Non-binary

Other

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* 7. Ethnic Background

White / Caucasian

Asian

Hispanic / Latino

Black / African American

Multi-Race / Ethnic Backgrounds

Other (please specify)

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* 8. Are you interested in learning more about Malcolm X College

Yes

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* 9. Are you a current NAHSE Member?

Yes

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* 10. If no, are you interested in learning more about NAHSE

Yes

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* 11. Select the factors you think contribute to high infant mortality rates in black women

Poverty and low socioeconomic status

Poor physical / mental health

Lack of prenatal care

Racism / implicit bias

Other