American Diabetes Association: Survey - Health Care Professionals Legal Advocacy Network Registration

1.

Question - Not Required - Facility

(Maximum response 255 chars, approx. 5 rows of text)

2.

Question - Not Required - Department

(Maximum response 255 chars, approx. 5 rows of text)

3.

Question - Not Required - Your Professional Website (or LinkedIn)

(Maximum response 255 chars, approx. 5 rows of text)

4.

Question - Not Required - Cell Phone

5.

Question - Not Required - Work Phone

6.

Question - Not Required - Which of the following credentials do you currently hold? Select all that apply.

	CDE
	DO
	MD
	SocialWorker
	RN
	NP
	PA
	PhD
	RPH
	RD
	Other

7.

Question - Not Required - Other Credential

(Maximum response 255 chars, approx. 5 rows of text)

8.

Question - Not Required - Specialty

(Maximum response 255 chars, approx. 5 rows of text)

9.

Question - Not Required - State to cover

	AK
	AL
	AR
	AZ
	CA
	CO
	CT
	DC
	DE
	FL
	GA
	HI
	IA
	ID
	IL
	IN
	KS
	KY
	LA
	MA
	MD
	ME
	MI
	MN
	MO
	MS
	MT
	NC
	ND
	NE
	NH
	NJ
	NM
	NV
	NY
	OH
	OK
	OR
	PA
	RI
	SC
	SD
	TN
	TX
	UT
	VA
	VT
	WA
	WI
	WV
	WY
	none

10.

Question - Not Required - Area of Interest

	Employment
	Education
	Daycare/Childcare
	Correctional Facilities
	Police Misconduct
	Public Accommodations
	Driver Licenses
	Other

11.

Question - Not Required - How would you like to help

	Assisting with the development of diabetes-related educational materials
	Educating individuals about their rights
	Making phone calls
	Writing letters
	Training
	Consulting with attorneys on legal cases
	Being an expert witness at trials
	Supporting the Association's legislative efforts
	New Member Recruitment

12.

Question - Not Required - Have you been involved with ADA

	Joined the Stop Diabetes movement
	Subscribed to Diabetes Forecast magazine
	Subscribed to a professional member publication
	Subscribed to e-newsletters
	Donated money
	Volunteered
	Attended a Diabetes EXPO
	Made purchases on the ADA online store
	Participated in Step Out
	Participated in Tour de Cure
	Child attended a Diabetes Camp
	Participated in an online community
	Participated in School Walk
	Attended the Scientific Sessions Conference
	Other

13.

Question - Not Required - Other engagement

(Maximum response 255 chars, approx. 5 rows of text)

14.

Question - Not Required - Do you want to become Diabetes Advocate?

15.

Question - Not Required - Additional Note

16.

Question - Not Required - If you want to recommend a colleague for us to contact for recruitment into the HCP Network or the Advocacy Attorney Network, please list their name(s), email address(es), and professional title(s).

17.

Question - Not Required - Ready to help?

yes

no

*18.

Question - Required - First Name

*19.

Question - Required - Last Name

*20.

Question - Required - email

(Maximum response 255 chars, approx. 5 rows of text)

21.

Question - Not Required - Street

(Maximum response 255 chars, approx. 5 rows of text)

22.

Question - Not Required - City

(Maximum response 255 chars, approx. 5 rows of text)

23.

Question - Not Required - state

24.

Question - Not Required - zipcode

25.

Question - Not Required - phone

26.

Question - Not Required - occupation