NHCTRC Youth Steering Committee Application: Step 1

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* 1. Name:

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* 2. Age:

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* 3. Address:

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* 4. City:

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* 5. State:

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* 6. Zip Code:

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* 7. Email:

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* 8. Phone Number:

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* 9. What is the best way to contact?

Phone call

Phone Text

Other (please specify)

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* 10. Do you have a disability:

Yes

I don’t know

I prefer not to say

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* 11. If yes, how would you describe it?

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* 12. What Gender do you identify with?

Girl or woman (including trangender girl or woman)

Boy or man (including transgender boy or man)

Nonbinary, genderfluid, or genderqueer

Indigenous or other cultural gender identity (such as two-spirit)

I am questioning: I am still figuring out my gender identity

I don’t know what this question means

I don’t want to answer this question

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* 13. What pronouns do you use? (Pronouns are words we use instead of names.)

she/her

He/him

They/them

Ze/hir

Other

Other (please specify)

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* 14. What sexual orientation do you identify with? Sexual orientation is about who you’re attracted to. There are many ways a person can describe their sexual orientation. Some people might need more than one word to describe the way they experience attraction. You can choose more than one word if more than one describes you.

Straight or heterosexual

Gay

Lesbian

Bisexual

Pansexual

Queer

Asexual or ace spectrum

Aromantic or aro spectrum

Indigenous or other cultural identity (such as two-spirit)

Questioning: I am still figuring out my sexual orientation

I don’t know what this question means

I want to describe my sexual orientation in my own words: [text box]

I don’t want to answer this question

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* 15. What is your race?

Indigenous, Native American, American Indian, or Alaska Native

Asian or Middle Eastern

Black or African American

Native Hawaiian or Pacific Islander

White

I don’t want to answer this question

Other (please specify)

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* 16. Some people also identify as Latinx or Hispanic.

Yes

I don’t know what this question is asking

I don’t want to answer this question

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* 17. What is your preferred language?

English

Spanish

Vietnamese

Korean

Arabic

Guajarati

Hindi

Russian

French/French Creole

Chinese

Somali

American Sign Language (ASL)

Other

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* 18. Do you make decisions about your healthcare?

Yes

I don’t know

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* 19. How comfortable are you talking about your health, healthcare, and needs?

Not comfortable at all

Somewhat comfortable

Fairly Comfortable

Very Comfortable

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* 20. After you finish this survey, you will be contacted by Rachel Shandler with more questions to help us to get to know you more. Will you need accommodations to finish the application?

NHCTRC Youth Steering Committee Application: Step 1

Question Title

* 1. Name:

Question Title

* 2. Age:

Question Title

* 3. Address:

Question Title

* 4. City:

Question Title

* 5. State:

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* 6. Zip Code:

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* 7. Email:

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* 8. Phone Number:

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* 9. What is the best way to contact?

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* 10. Do you have a disability:

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* 11. If yes, how would you describe it?

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* 12. What Gender do you identify with?

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* 13. What pronouns do you use? (Pronouns are words we use instead of names.)

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* 15. What is your race?

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* 16. Some people also identify as Latinx or Hispanic.

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* 17. What is your preferred language?

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* 18. Do you make decisions about your healthcare?

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* 19. How comfortable are you talking about your health, healthcare, and needs?

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* 20. After you finish this survey, you will be contacted by Rachel Shandler with more questions to help us to get to know you more. Will you need accommodations to finish the application?

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* 21. If yes, what accommodations do you need?

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* 22. How did you hear about this opportunity?