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Staff Profile Questionnaire
Staff Profile Questionnaire
Full Name
*
Pronouns
*
they/them/ theirs
she/her/hers
he/him/his
Other
Pronouns
Job Title
*
Department
*
Care Coordination
Food & Nutrition
Housing
Hepatitis C
Mental Health
Administration
Other
Department
Hire Date
*
Years in Current Position
*
Birthdate
Age Range
18 - 30
31 - 44
45-64
65+
Race/Ethnicity
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Asian
Black or African American
Hispanic or Latinx
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
White
Two or more races
Other
Race/Ethnicity
Gender
*
Female
Male
Non-binary
Other
Gender
Identify as Trans?
*
YES
NO
Identify as LGBTQIA+
*
YES
NO
Highest Level of Education
*
High school or Equivalent
Technical or Occupational Certificate
Associate Degree
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Master’s Degree
Doctorate
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Please list any professional licenses you hold:
*
Skills - check all that apply
Written Communication
Oral Communication/Presentation
Collaborative
Critical Thinking/Problem Solving
IT/Computer savvy
Graphics & Design
Organization
What other tasks or responsibilities do others at the agency ask you to help with?
What other tasks or responsibilities do others at the agency ask you to help with?
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