Maternal Health Equity Focus Groups
Please fill out this form in order to participate in a focus group facilitated by Georgia IMPROVE and Morehouse School of Medicine's Center for Maternal Health Equity. If you have any questions, please contact Brittney Newton at bnewton@msm.edu.
Name
*
First Name
Last Name
Do you live in Georgia?
*
Yes
No
Do you identify as African American or Black or Hispanic or Latinx?
*
Yes
No
Are you pregnant or have you given birth within the last 18 months?
*
Yes
No
Race/Ethnicity
*
African American/Black
White
Hispanic/Latinx
Native Hawaiian and other Pacific Islander
American Indian/Alaskan Native
Two or more races
Other
County
*
Zip Code
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred method of contact:
*
Phone
Email
No preference
Would you like to participate in a focus group?
*
Yes
No
If you are selected to participate in a focus group, you will be asked to join a two-hour Zoom call. Please select the month in which you would like to join a discussion.
September 2022
October 2022
Signature
Please verify that you are human
*
Submit
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