Focus Group Participant Intake Survey
Our Community Birth Center is a nonprofit organization in Lane County that is actively working to open a new community-based nurse midwifery birth center, health clinic, and lactation service. Your completion of this survey is voluntary (it is not required by anyone). By taking this survey, you are giving permission to Our Community Birth Center to contact you and invite you to participate in a Focus Group. There is no payment or prize for completing this survey; however, if you are invited and do participate in a focus group then you will receive a gift card as a thank you for your time.

A focus group is a small group discussion in which a facilitator will ask questions to help gather information. The goal of our focus groups is to learn about what people want and need from pregnancy, birth and postpartum care in our local community and how people choose where to seek care. This will help us to develop a new birth center that effectively fulfills the needs of people in our community.

Your answers will be kept private and only the Executive Director, Facilitator, and Co-facilitator of the focus groups will have access to the information you provide. This information about you will help us to form focus groups and then match each group with a facilitator.

If you have questions you can contact us at OurCommunityBirthCenter@gmail.com. If you would like to learn more about Our Community Birth Center, please visit www.ourcommunitybirthcenter.org. You can also find and follow us on Facebook at www.facebook.com/ourcommunitybirthcenter.
Sign in to Google to save your progress. Learn more
Email *
First and Last Name *
Phone number *
What is your primary language? *
Have you given birth in the last 5 years? *
If you have not given birth before, do you hope to get pregnant in the next 5 years? *
In which county do you currently live? *
What is the name of the city or town in which you live?
How would you describe your current living situation?
Clear selection
What is your age?
What race or ethnicity do you identify with? *
Required
Do you identify as BIPOC (Black, Indigenous, or Person of Color)? *
Do you identify as LGBTQIA+? *
Were you born in the US?
Clear selection
What culture(s) do you identify with? (optional)
Do you identify as religious? If yes, what religion do you identify with? (optional)
Do you have access to a private space with internet and video chat capabilities on a computer, phone, or other device which you could use to participate in a focus group? *
Would you like to be added to Our Community Birth Center's email list to receive updates via email? *
Do you have any questions for the organizers of Our Community Birth Center's focus groups?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms