Covid Tell-Us-Your-Story Forms
Other Experiences During Covid
Your contact information will only be shared as you specify below.
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First name
*
Last name
*
Email address
*
City
*
State
*
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
Region
*
ZIP Code
*
Postal code
Phone (for follow-up questions)
Hospital/Facility Name
Tell us your story in as much detail as you wish.*
Are you a health care worker?*
Yes
No
Are you a Registered Nurse?*
Yes
No
What health care setting do you currently work in?*
Hospital
Outpatient clinic
Home care or hospice
Skilled nursing facility or long-term care
Medical offices
Retired
Currently not employed as a nurse
Other
If "Other", please specify
Can we share your story anonymously?*
Yes
No
Can we share your story with only your first name and city, state?*
Yes
No
Can we share your story publicly with your name and location?*
Yes
No
Can we contact you about your story?*
Yes
No
* denotes required field
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