Virtual Peer Support Inquiry

2. How do you prefer to be contacted? *This question is required.

• Phone
• Email
• No preference

3. Gender:

• Man
• Woman
• Non-binary

4. Are you Hispanic or Latino(a)?

• Yes
• No

5. Race: (select all that apply)

• Asian
• Black
• Native American or Alaska Native
• White
• Multiracial/mixed race
• Other - Write In Please enter an 'other' value for this selection.

6. What type of setting do you work in? (select all that apply)

• Ambulatory care
• Home health
• Hospital
• Nursing home
• Office setting
• Urgent care

7. Which best describes your role? (select all that apply)

• Administration (e.g., unit coordinator, practice manager, C-suite)
• Advanced practice provider (e.g, PA)
• Home care (e.g., PCA, home health aide)
• Nursing (e.g., NP)
• Physician
• Other clinical (e.g., PT, OT, RT, pharmacy)
• Other non-clinical (e.g., environmental services, public safety officer)
• Other Please enter an 'other' value for this selection.

11. How did you find the Virtual Peer Support Network? 

• Betsy Lehman Center website
• Colleague
• Employer
• Friend/family member
• Hospital
• Internet search
• Mass Medical Society (MMS)
• Massachusetts Health & Hospital Association (MHA)
• Massachusetts Nurses Association (MNA)
• Patient Safety Beat (PSB)
• Other - Write In Please enter an 'other' value for this selection.