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CIC Interest Form
Tell us about yourself for our Community Insight Committee for the Williamsburg Integrated Care Initiative
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* Indicates required question
Are you willing to share your experiences with a small group and have them be recorded or written down?
*
Yes
Yes, but without my full name being shared
Yes, but no audio or video recording please
Are you willing to listen to others share their health care experiences, respectfully and with an open-minded attitude?
*
Yes
What area of health care do you have the most personal experience with?
Mental health care
Pediatrics
Specialty care
Health education
Peer support
Primary Care
Urgent Care
Dentistry
Pharmacy
Providing social services that include health
Providing other types of health care
Clear selection
Where do you live?
James City County
York County
City of Williamsburg
Poquoson
Other:
Clear selection
Are you a caregiver? (For children, geriatric adults or people living with disabilities.)
Yes
No
Occasionally
I am a professional caregiver
Clear selection
What is your best regular availability?
Weekdays
Weeknights
Weekend days
A specific day of the week (put in Other)
Other:
Clear selection
Are you willing to meet virtually and in person? Or is there one preferred?
Virtually preferred
In person preferred
Other:
Clear selection
Are you willing to receive information (via email) about this project as it continues?
Yes
No
Maybe
Clear selection
Please provide your name and email address.
*
Your answer
Notes or questions can go here, and we will do our best to reply if you leave your email address:
Your answer
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