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CHNA Focus Group Registration Form
Tuesday March 30 from 6:00 to 7:00 PM
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Email
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Your email
Last Name or Initial
Your answer
First Name
Your answer
Organization/Employer (Not required)
Your answer
This meeting will be recorded. Audio and video recordings are for note taking purposes only and will not be shared with anyone outside of the CHNA team. Any quotes you provide will not be attributed to you in any printed/published materials.
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I understand
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Which of the following health service areas do you live and/or work in? (Check all that apply)
*
Heywood Hospital (Ashburnham, Gardner, Hubbardston, Templeton, Winchendon, Westminster)
Athol Hospital (Athol, Irving, New Salem, Orange, Petersham, Phillipston, Royalston, Warwick, or Wendell)
UMass Memorial Health Alliance Clinton Hospital (Ashburnham, Ashby, Bolton. Clinton, Fitchburg, Harvard, Gardner, Lancaster, Leominster, Lunenburg, Princeton, Sterling, Townsend, Westminster)
Other:
(Optional) What is your primary concern regarding the health care needs of the community you live/work in? (Health is defined in broad terms and can include physical health challenges like diabetes or cancer, and can also include social determinants of health such as housing and transportation)
Your answer
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