Health Equity Committee Application/Interest Survey

Application/Interest Survey

Health Equity Committee
Please complete this form to help us learn a little more about you. We will contact you by phone to follow up about your application to join the Health Equity Committee.

Note: Your responses to these questions will NOT affect your current enrollment or benefits, and they will not change whether you are selected to join the Health Equity Committee. Your individual responses will be kept private.

Please note, all information provided is confidential.
Please provide your name, preferred phone number and zip code so that we may contact you about your interest in joining the Health Equity Committee.
Name*

First NameLast Name
Email*
example@example.com
Tufts Member ID*
Phone Number*
Zip Code*
We are committed to creating welcoming, inclusive, and accessible Health Equity Committee meetings. What, if any, accommodations do you need to help you fully participate in these meetings? (Choose all that apply):

I need help getting transportation (for in-person meetings).I need help getting childcare.I don’t have the right technology or internet service (for virtual meetings).I need accommodations because of my mobility.I need accommodations because of my sight/vision.I need accommodations because of my hearing.Not applicableOther
The following questions tell us a little about you.
What is your gender identity? Please select all that apply.

WomanManTransgenderNon-binary/non-conformingUnknownPrefer not to respond
What is your race? Please select all that apply.

AsianBlack/African AmericanMulti-RacialNative American/AlaskanNative Hawaiian/Pacific IslanderWhitePrefer not to respondOther
Hispanic?

YesNo
What is your ethnicity? Select all that apply.

AfricanAmericanAsian IndianBrazilianCape VerdeanCaribbean IslanderCentral AmericanChineseEuropeanHaitianMiddle Eastern or North AfricanPortugueseRussianPrefer not to respondOther
Will you need translation services?

YesNo
What is your primary language spoken at home?

EnglishSpanishPortugueseHaitian CreoleChinesePrefer not to respondOther
Language preference

EnglishPortugueseSpanishHaitian Creole
Should be Empty: