Healthcare Professionals for Pediatric Protection
Signature Information
Full Name
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City
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State
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Email address (collected solely to prevent duplicate entries; not public unless explicit permission is granted elsewhere in this form)
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Are you a healthcare worker?
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Yes
No
Professional Information
If yes, please specify your role:
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Please Select
Physician (MD/DO)
Physician Assistant (PA)
Nurse Practitioner (NP)
Registered Nurse (RN)
Licensed Mental Health Professional
Certified Allied Health Professional
Medical trainee
Public Health (MPH) or Higher
Years in Practice?
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Student/trainee
1-5 years
6-10
11-20
20+
Which patient population do you primarily serve?
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Infants
Children
Adolescents
Families
Adults
Testimony & Consent
Why does this issue matter to you?
May we contact you about updates or advocacy opportunities related to the protection, release, and medical care of children in government custody?
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Please Select
Yes
No, thank you
May we share your comment anonymously in advocacy or media?
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Yes
No, thank you
Attestation
I affirm that the information provided is accurate and that I am signing in good faith to support the protection, release, and medical care of children in government custody.
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Affirm
Submit
Should be Empty: