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City and State are required.","type":"control_text"},{"description":"Please select the most appropriate service area. If you serve multiple counties, and\u002For states, name those service areas below in the additional information section.","name":"serviceArea","qid":"15","text":"Service Area","type":"control_checkbox"},null,{"description":"If you don't operate a hotline, select 'Not Applicable'.","name":"ifYes","qid":"17","text":"If yes, what signal types can be used to access hotline services? (Select all that apply)","type":"control_checkbox"},null,null,{"description":"Indicate all the types of crime in which the organization is able to assist.","name":"crimeTypesselect","qid":"20","text":"Crime Types聽(Select all that apply)","type":"control_checkbox"},null,{"description":"Indicate the types of services the organization is able to provide. Should an organization wish to provide additional information about any services provided, that information can be added to the additional information section at the end of the form.","name":"servicesProvidedselect","qid":"22","text":"Services Provided聽(Select all that apply)","type":"control_checkbox"},{"description":"Please select the appropriate type(s) of fee structure.","name":"feescostOf","qid":"23","text":"Fees\u002FCost of Services聽(Select all that apply)","type":"control_checkbox"},{"description":"","name":"serviceAccess","qid":"24","text":"Service Access Method(s) (Select all that apply)","type":"control_checkbox"},null,null,null,{"description":"Should your program\u002Forganization have age restrictions or work with specific age groups, please indicate that information in the additional information section.","name":"agesGroups","qid":"28","text":"Ages Groups Served聽(Select all that apply)","type":"control_checkbox"},null,{"description":"Should your program\u002Forganization have gender restrictions or work with a specific gender(s), please indicate that information in the additional information section.","name":"gendersServedselect","qid":"30","text":"Genders Served聽(Select all that apply)","type":"control_checkbox"},null,{"description":"Please identify any population(s) that your program\u002Forganization provides specialized programming\u002Fservices for.","name":"specializedProgrammingservicesselect","qid":"32","text":"Specialized Programming\u002FServices聽(Select all that apply)","type":"control_checkbox"},null,null,{"description":"Please indicate the languages the program\u002Forganization staff are proficient in.","name":"staffLanguage","qid":"35","text":"Staff Language Skills聽(Select all that apply)","type":"control_checkbox"},null,{"name":"ltpgtltspanStylecolor37","qid":"37","text":"Private Program Information\nPlease list the most appropriate staff member(s) our team should contact for questions about the information submitted on this form. This information will not be publicly shared by our staff.\n ","type":"control_text"},{"name":"ltpgtltspanStylecolor38","qid":"38","text":"Private Address\nThis information will not be shared publicly.\n ","type":"control_text"},null,{"name":"ltpgtltspanStylecolor40","qid":"40","text":"Additional Information\nPlease use this space to add any additional information the organization would like our staff to know. This could include any of the following information: \n\nThe best way to make referrals or important intake information or criteria\nRelevant hotline details\nIf you serve multiple counties, and\u002For states, name those service areas\nInformation about gender, age, or population restrictions\nServices provided to special populations or specific disability accommodations\nAdditional information about any services provided\n","type":"control_text"},{"name":"submit","qid":"41","text":"Submit","type":"control_button"},null,{"description":"","name":"organizationName","qid":"43","subLabel":"Please provide the name of the organization that this submission applies to:聽e.g National Center for Victims of Crime.","text":"Organization Name","type":"control_textbox"},{"description":"","mde":"No","name":"programDescription44","qid":"44","subLabel":"Please provide a description of your program. If not applicable, please provide a聽description of your organization.","text":"Program Description (if applicable)","type":"control_textarea","wysiwyg":"Disable"},{"description":"If not applicable, please type \"not applicable\".","name":"programName","qid":"45","subLabel":"Please enter the program name that applies to this submission, if appropriate:聽e.g VictimConnect Resource Center.","text":"Program Name (if applicable)","type":"control_textbox"},{"name":"input46","qid":"46","text":"Program Eligibility Confirmation\nPlease provide information for one of the following (This information will not be shared publicly):","type":"control_text"},{"name":"input47","qid":"47","text":"Basic Information","type":"control_text"},{"name":"input48","qid":"48","text":"Program Eligibility","type":"control_text"},{"description":"If no, please type \"not applicable\".","name":"ifYes49","qid":"49","subLabel":"","text":"If yes, please list one of your government funding agencies.","type":"control_textbox"},{"description":"If no, please type \"not applicable\".","name":"ifyourOrganizationprogram","qid":"50","subLabel":"","text":"If聽your organization\u002Fprogram belongs to a regional task force, multidisciplinary team, or聽etc., please provide a link to a website that lists your organization as an active member聽or submit a letter of support from your group.","type":"control_textbox"},null,{"name":"divider52","qid":"52","type":"control_divider"},{"name":"divider53","qid":"53","type":"control_divider"},{"name":"divider54","qid":"54","type":"control_divider"},{"name":"input55","qid":"55","text":"Public Program Information\n \n \nPublic Contact Information\nPlease do not provide any confidential information.","type":"control_text"},{"description":"","name":"address","qid":"56","text":"Address","type":"control_address"},null,null,null,{"description":"","name":"ifYour","qid":"60","text":"If your program is open 24 hours\u002Fday, please input a 24-hour range (e.g. 12:00 AM Until 12:00 AM).","type":"control_time"},null,null,null,null,null,{"description":"If no, please type \"not applicable\".","mde":"No","name":"ifYes66","qid":"66","subLabel":"","text":"If Yes, please describe your intake process below.","type":"control_textarea","wysiwyg":"Disable"},null,null,{"name":"divider","qid":"69","type":"control_divider"},{"name":"input70","qid":"70","text":"Due to issues with staff turnover, name changes, etc., it is requested that you provide a non-named email address in the event that other emails to your organization bounce and the VictimConnect Resource Center needs to contact your organization. For example, several members of our team check hotlineleadership@victimsofcrime.org.","type":"control_text"},{"description":"","name":"primaryContact","qid":"71","subLabel":"","text":"Primary Contact First Name","type":"control_textbox"},{"description":"","name":"primaryContact72","qid":"72","subLabel":"","text":"Primary Contact Last Name","type":"control_textbox"},null,{"description":"","name":"primaryContact74","qid":"74","text":"Primary Contact Phone ","type":"control_phone"},{"description":"","name":"primaryContact75","qid":"75","subLabel":"example@example.com","text":"Primary Contact Email","type":"control_email"},{"description":"","name":"secondaryContact","qid":"76","subLabel":"","text":"Secondary Contact First Name","type":"control_textbox"},{"description":"","name":"secondaryContact77","qid":"77","subLabel":"","text":"Secondary Contact Last Name","type":"control_textbox"},{"description":"","name":"secondaryContact78","qid":"78","text":"Secondary Contact Phone ","type":"control_phone"},{"description":"","name":"secondaryContact79","qid":"79","subLabel":"example@example.com","text":"Secondary Contact Email","type":"control_email"},{"description":"This information will not be shared publicly.\n\n","name":"backupOrganization","qid":"80","subLabel":"example@example.com","text":"Backup Organization Contact Email","type":"control_email"},{"description":"","name":"address81","qid":"81","text":"Address","type":"control_address"},{"description":"","mde":"No","name":"input82","qid":"82","subLabel":"Please indicate whether or not you want the information you provide here made public聽through our hotline services.","text":"","type":"control_textarea","wysiwyg":"Disable"},{"description":"","name":"programInclusion83","qid":"83","text":"Program Inclusion Selection聽(Select one option)","type":"control_radio"},{"description":"","name":"doesYour84","qid":"84","text":"Does your organization\u002Fprogram receive government funding (local, state, federal)?","type":"control_radio"},{"description":"","name":"doesThe85","qid":"85","text":"Does the organization\u002Fprogram operate a hotline?","type":"control_radio"},{"description":"","name":"hoursOf86","qid":"86","text":"Hours of Operation","type":"control_radio"},{"description":"","name":"doesThe","qid":"87","text":"Does the organization have and maintain a policy to protect the identity and information of the victims they serve?","type":"control_radio"},{"description":"","name":"doesYour","qid":"88","text":"Does your organization\u002Fprogram have an intake process?","type":"control_radio"},{"description":"","name":"parentguardianConsent89","qid":"89","text":"Parent\u002FGuardian Consent Required for Minors?","type":"control_radio"},{"description":"","name":"doYou90","qid":"90","text":"Do you have access to interpretation services?","type":"control_radio"},{"description":"If you are submitting a letter of support, please upload it here. ","name":"input91","qid":"91","subLabel":"If you are submitting a letter of support, please upload it here. ","text":"","type":"control_fileupload"},null,{"description":"","name":"input93","qid":"93","subLabel":"If you selected other, please write in the language(s).","text":"","type":"control_textbox"},null,{"description":"","name":"input95","qid":"95","subLabel":"If you selected other, please write a short sentence about your specialized programming\u002Fservices.","text":"","type":"control_textbox"}]);}, 20); </script> </head> <body> <form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();" action="https://ncvc.jotform.com/submit/211883668810059" method="post" enctype="multipart/form-data" name="form_211883668810059" id="211883668810059" accept-charset="utf-8" autocomplete="off"><input type="hidden" name="formID" value="211883668810059" /><input type="hidden" id="JWTContainer" value="" /><input type="hidden" id="cardinalOrderNumber" value="" /><input type="hidden" id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1732458356200" /><input type="hidden" id="submitSource" name="submitSource" value="unknown" /><input type="hidden" id="buildDate" name="buildDate" value="1732458356200" /><input type="hidden" name="eventObserver" value="1" /> <div role="main" class="form-all"> <ul class="form-section page-section"> <li class="form-line" data-type="control_text" id="id_1"> <div id="cid_1" class="form-input-wide"> <div id="text_1" class="form-html" data-component="text" tabindex="0"> <p style="text-align: center;">聽</p> <p style="text-align: center;"><strong><span style="color: #000000; font-size: 18pt;">VictimConnect Resource Inclusion Form</span></strong></p> <p>聽</p> <p><strong><span style="color: #000000;">Instructions:</span></strong></p> <ul> <li><span style="color: #000000;">To learn more about the program inclusion requirements, read the eligibility criteria <a href="https://victimconnect.org/resources/eligibility-criteria/" target="_blank" rel="nofollow">here</a>.聽</span></li> <li><span style="color: #000000;">If you have multiple programs that you want to be considered for inclusion,</span> <span style="color: #000000;">please submit one form per each program.</span></li> <li><span style="color: #000000;">Complete and return all forms to: <a href="mailto:hotlineleadership@victimsofcrime.org" target="_blank" rel="nofollow">hotlineleadership@victimsofcrime.org</a>聽or submit online.</span></li> <li><span style="color: #000000;">If you have any questions or issues submitting your form online, please contact聽</span><span style="color: #000000;">us at <a href="mailto:hotlineleadership@victimsofcrime.org" target="_blank" rel="nofollow">hotlineleadership@victimsofcrime.org</a>.</span></li> </ul> </div> </div> </li> <li class="form-line" data-type="control_divider" id="id_52"> <div id="cid_52" class="form-input-wide"> <div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px"></div> </div> </li> <li class="form-line" data-type="control_text" id="id_47"> <div id="cid_47" class="form-input-wide"> <div id="text_47" class="form-html" data-component="text" tabindex="0"> <p style="text-align: center;"><strong><span style="font-size: 18pt;">Basic Information</span></strong></p> </div> </div> </li> <li class="form-line jf-required" data-type="control_textbox" id="id_43"><label class="form-label form-label-left form-label-auto" id="label_43" for="input_43" aria-hidden="false"> Organization Name<span class="form-required">*</span> </label> <div id="cid_43" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_43" name="q43_organizationName" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_43 sublabel_input_43" required="" value="" /><label class="form-sub-label" for="input_43" id="sublabel_input_43" style="min-height:13px">Please provide the name of the organization that this submission applies to:聽e.g National Center for Victims of Crime.</label></span> </div> </li> <li class="form-line jf-required" data-type="control_textbox" id="id_45"><label class="form-label form-label-left form-label-auto" id="label_45" for="input_45" aria-hidden="false"> Program Name (if applicable)<span class="form-required">*</span> </label> <div id="cid_45" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_45" name="q45_programName" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_45 sublabel_input_45" required="" value="" /><label class="form-sub-label" for="input_45" id="sublabel_input_45" style="min-height:13px">Please enter the program name that applies to this submission, if appropriate:聽e.g VictimConnect Resource Center.</label></span> </div> </li> <li class="form-line jf-required" data-type="control_textarea" id="id_44"><label class="form-label form-label-left form-label-auto" id="label_44" for="input_44" aria-hidden="false"> Program Description (if applicable)<span class="form-required">*</span> </label> <div id="cid_44" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align:top"><textarea id="input_44" class="form-textarea validate[required]" name="q44_programDescription44" cols="40" rows="6" data-component="textarea" required="" aria-labelledby="label_44 sublabel_input_44"></textarea><label class="form-sub-label" for="input_44" id="sublabel_input_44" style="min-height:13px">Please provide a description of your program. If not applicable, please provide a聽description of your organization.</label></span> </div> </li> <li class="form-line" data-type="control_divider" id="id_53"> <div id="cid_53" class="form-input-wide"> <div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px"></div> </div> </li> <li class="form-line" data-type="control_text" id="id_48"> <div id="cid_48" class="form-input-wide"> <div id="text_48" class="form-html" data-component="text" tabindex="0"> <p style="text-align: center;"><span style="font-size: 18pt;"><strong>Program Eligibility</strong></span></p> </div> </div> </li> <li class="form-line" data-type="control_text" id="id_46"> <div id="cid_46" class="form-input-wide"> <div id="text_46" class="form-html" data-component="text" tabindex="0"> <p><strong>Program Eligibility Confirmation</strong></p> <p>Please provide information for <strong>one</strong> of the following (This information will not be shared publicly):</p> </div> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_84"><label class="form-label form-label-left form-label-auto" id="label_84" aria-hidden="false"> Does your organization/program receive government funding (local, state, federal)?<span class="form-required">*</span> </label> <div id="cid_84" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_84" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_84" type="radio" class="form-radio validate[required]" id="input_84_0" name="q84_doesYour84" required="" value="Yes" /><label id="label_input_84_0" for="input_84_0">Yes</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_84" type="radio" class="form-radio validate[required]" id="input_84_1" name="q84_doesYour84" required="" value="No" /><label id="label_input_84_1" for="input_84_1">No</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_textbox" id="id_49"><label class="form-label form-label-left form-label-auto" id="label_49" for="input_49" aria-hidden="false"> If yes, please list one of your government funding agencies.<span class="form-required">*</span> </label> <div id="cid_49" class="form-input jf-required"> <input type="text" id="input_49" name="q49_ifYes49" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_49" required="" value="" /> </div> </li> <li class="form-line jf-required" data-type="control_textbox" id="id_50"><label class="form-label form-label-left form-label-auto" id="label_50" for="input_50" aria-hidden="false"> If聽your organization/program belongs to a regional task force, multidisciplinary team, or聽etc., please provide a link to a website that lists your organization as an active member聽or submit a letter of support from your group.<span class="form-required">*</span> </label> <div id="cid_50" class="form-input jf-required"> <input type="text" id="input_50" name="q50_ifyourOrganizationprogram" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_50" required="" value="" /> </div> </li> <li class="form-line" data-type="control_fileupload" id="id_91"><label class="form-label form-label-left form-label-auto" id="label_91" for="input_91" aria-hidden="true"> </label> <div id="cid_91" class="form-input"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top"> <div class="qq-uploader-buttonText-value">Browse Files</div><input type="file" id="input_91" name="q91_input91[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif" data-limit-file-size="Yes" data-file-maxsize="10854" data-file-minsize="0" data-file-limit="" data-component="fileupload" /><label class="form-sub-label" for="input_91" style="min-height:13px">If you are submitting a letter of support, please upload it here. </label> </span><span style="display:none" class="cancelText">Cancel</span><span style="display:none" class="ofText">of</span></div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_5"><label class="form-label form-label-left form-label-auto" id="label_5" aria-hidden="false"> Organization Type (Select all that apply)<span class="form-required">*</span> </label> <div id="cid_5" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_5" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_5" type="checkbox" class="form-checkbox validate[required]" id="input_5_0" name="q5_organizationType[]" required="" value="Direct Service Provider" /><label id="label_input_5_0" for="input_5_0">Direct Service Provider</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_5" type="checkbox" class="form-checkbox validate[required]" id="input_5_1" name="q5_organizationType[]" required="" value="Indirect Service Provider" /><label id="label_input_5_1" for="input_5_1">Indirect Service Provider</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_5" type="checkbox" class="form-checkbox validate[required]" id="input_5_2" name="q5_organizationType[]" required="" value="Law Enforcement Victim Service Department" /><label id="label_input_5_2" for="input_5_2">Law Enforcement Victim Service Department</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_5" type="checkbox" class="form-checkbox validate[required]" id="input_5_3" name="q5_organizationType[]" required="" value="Government Agency Program" /><label id="label_input_5_3" for="input_5_3">Government Agency Program</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_5" type="checkbox" class="form-checkbox validate[required]" id="input_5_4" name="q5_organizationType[]" required="" value="Advocacy Organization" /><label id="label_input_5_4" for="input_5_4">Advocacy Organization</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_5" type="checkbox" class="form-checkbox validate[required]" id="input_5_5" name="q5_organizationType[]" required="" value="Faith-Based Organization" /><label id="label_input_5_5" for="input_5_5">Faith-Based Organization</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_83"><label class="form-label form-label-left form-label-auto" id="label_83" aria-hidden="false"> Program Inclusion Selection聽(Select one option)<span class="form-required">*</span> </label> <div id="cid_83" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_83" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_83" type="radio" class="form-radio validate[required]" id="input_83_0" name="q83_programInclusion83" required="" value="VictimConnect Resource Map AND Internal Database" /><label id="label_input_83_0" for="input_83_0">VictimConnect Resource Map AND Internal Database</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_83" type="radio" class="form-radio validate[required]" id="input_83_1" name="q83_programInclusion83" required="" value="Internal Database ONLY" /><label id="label_input_83_1" for="input_83_1">Internal Database ONLY</label></span></div> </div> </li> <li class="form-line" data-type="control_text" id="id_7"> <div id="cid_7" class="form-input-wide"> <div id="text_7" class="form-html" data-component="text" tabindex="0"> <p><em>If you select <strong>Internal Database ONLY</strong>, visitors to the VictimConnect Resource Center will only be able to access your public information by communicating with a Victim Assistance Specialist via our helpline.</em></p> <p><br /><em>If you select to be included on our <a href="https://victimconnect.org/resources/search-resources/" target="_blank" rel="nofollow">VictimConnect Resource Map</a>, some of the public information you provide about your organization/program will be placed on our website; such as your program name and description, contact information, website link, service area/location, and services provided.</em></p> </div> </div> </li> <li class="form-line" data-type="control_divider" id="id_54"> <div id="cid_54" class="form-input-wide"> <div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px"></div> </div> </li> <li class="form-line" data-type="control_text" id="id_55"> <div id="cid_55" class="form-input-wide"> <div id="text_55" class="form-html" data-component="text" tabindex="0"> <p style="text-align: center;"><strong><span style="font-size: 18pt;">Public Program Information</span></strong></p> <p style="text-align: left;">聽</p> <p style="text-align: left;">聽</p> <p style="text-align: left;"><strong>Public Contact Information</strong></p> <p style="text-align: left;">Please do not provide any confidential information.</p> </div> </div> </li> <li class="form-line jf-required" data-type="control_textbox" id="id_8"><label class="form-label form-label-left form-label-auto" id="label_8" for="input_8" aria-hidden="false"> Website<span class="form-required">*</span> </label> <div id="cid_8" class="form-input jf-required"> <input type="text" id="input_8" name="q8_website" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_8" required="" value="" /> </div> </li> <li class="form-line" data-type="control_textbox" id="id_9"><label class="form-label form-label-left form-label-auto" id="label_9" for="input_9" aria-hidden="false"> Fax </label> <div id="cid_9" class="form-input"> <input type="text" id="input_9" name="q9_fax" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_9" value="" /> </div> </li> <li class="form-line" data-type="control_email" id="id_10"><label class="form-label form-label-left form-label-auto" id="label_10" for="input_10" aria-hidden="false"> Email </label> <div id="cid_10" class="form-input"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_10" name="q10_email" class="form-textbox validate[Email]" data-defaultvalue="" autoComplete="nope" size="30" data-component="email" aria-labelledby="label_10 sublabel_input_10" value="" /><label class="form-sub-label" for="input_10" id="sublabel_input_10" style="min-height:13px">example@example.com</label></span> </div> </li> <li class="form-line jf-required" data-type="control_phone" id="id_11"><label class="form-label form-label-left form-label-auto" id="label_11" for="input_11_area" aria-hidden="false"> Phone #<span class="form-required">*</span> </label> <div id="cid_11" class="form-input jf-required"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode"><input type="tel" id="input_11_area" name="q11_phone[area]" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" data-component="areaCode" aria-labelledby="label_11 sublabel_11_area" required="" value="" /><span class="phone-separate" aria-hidden="true">聽-</span><label class="form-sub-label" for="input_11_area" id="sublabel_11_area" style="min-height:13px">Area Code</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone"><input type="tel" id="input_11_phone" name="q11_phone[phone]" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" data-component="phone" aria-labelledby="label_11 sublabel_11_phone" required="" value="" /><label class="form-sub-label" for="input_11_phone" id="sublabel_11_phone" style="min-height:13px">Phone Number</label></span></div> </div> </li> <li class="form-line" data-type="control_phone" id="id_12"><label class="form-label form-label-left form-label-auto" id="label_12" for="input_12_area" aria-hidden="false"> Additional Phone # </label> <div id="cid_12" class="form-input"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode"><input type="tel" id="input_12_area" name="q12_additionalPhone[area]" class="form-textbox" data-defaultvalue="" autoComplete="nope" data-component="areaCode" aria-labelledby="label_12 sublabel_12_area" value="" /><span class="phone-separate" aria-hidden="true">聽-</span><label class="form-sub-label" for="input_12_area" id="sublabel_12_area" style="min-height:13px">Area Code</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone"><input type="tel" id="input_12_phone" name="q12_additionalPhone[phone]" class="form-textbox" data-defaultvalue="" autoComplete="nope" data-component="phone" aria-labelledby="label_12 sublabel_12_phone" value="" /><label class="form-sub-label" for="input_12_phone" id="sublabel_12_phone" style="min-height:13px">Phone Number</label></span></div> </div> </li> <li class="form-line" data-type="control_textbox" id="id_13"><label class="form-label form-label-left form-label-auto" id="label_13" for="input_13" aria-hidden="false"> Hotline # </label> <div id="cid_13" class="form-input"> <input type="text" id="input_13" name="q13_hotline" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_13" value="" /> </div> </li> <li class="form-line" data-type="control_text" id="id_14"> <div id="cid_14" class="form-input-wide"> <div id="text_14" class="form-html" data-component="text" tabindex="0"> <p><strong><span style="color: #000000;">Public Address</span></strong></p> <p><span style="color: #000000;">Please do not provide any confidential information. City and State are required.</span></p> </div> </div> </li> <li class="form-line jf-required" data-type="control_address" id="id_56" data-compound-hint="123 Main St.,STE 1336,Birmingham,AL,11111,"><label class="form-label form-label-left form-label-auto" id="label_56" for="input_56_addr_line1" aria-hidden="false"> Address<span class="form-required">*</span> </label> <div id="cid_56" class="form-input jf-required"> <div summary="" class="form-address-table jsTest-addressField"> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_56_addr_line1" name="q56_address[addr_line1]" class="form-textbox form-address-line" data-defaultvalue="" autoComplete="nope" placeholder="123 Main St." data-component="address_line_1" aria-labelledby="label_56 sublabel_56_addr_line1" value="" /><label class="form-sub-label" for="input_56_addr_line1" id="sublabel_56_addr_line1" style="min-height:13px">Street Address</label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_56_addr_line2" name="q56_address[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autoComplete="nope" placeholder="STE 1336" data-component="address_line_2" aria-labelledby="label_56 sublabel_56_addr_line2" value="" /><label class="form-sub-label" for="input_56_addr_line2" id="sublabel_56_addr_line2" style="min-height:13px">Street Address Line 2</label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_56_city" name="q56_address[city]" class="form-textbox validate[required] form-address-city" data-defaultvalue="" autoComplete="nope" placeholder="Birmingham" data-component="city" aria-labelledby="label_56 sublabel_56_city" required="" value="" /><label class="form-sub-label" for="input_56_city" id="sublabel_56_city" style="min-height:13px">City</label></span></span><span class="form-address-line form-address-state-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_56_state" name="q56_address[state]" class="form-textbox validate[required] form-address-state" data-defaultvalue="" autoComplete="nope" placeholder="AL" data-component="state" aria-labelledby="label_56 sublabel_56_state" required="" value="" /><label class="form-sub-label" for="input_56_state" id="sublabel_56_state" style="min-height:13px">State (Acronym Only)</label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_56_postal" name="q56_address[postal]" class="form-textbox form-address-postal" data-defaultvalue="" autoComplete="nope" placeholder="11111" data-component="zip" aria-labelledby="label_56 sublabel_56_postal" value="" /><label class="form-sub-label" for="input_56_postal" id="sublabel_56_postal" style="min-height:13px">Zip Code</label></span></span><span class="form-address-line form-address-country-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><select class="form-dropdown validate[required] form-address-country" name="q56_address[country]" id="input_56_country" data-component="country" required="" aria-labelledby="label_56 sublabel_56_country" autoComplete="section-input_56 country"> <option value="">Please Select</option> <option value="Afghanistan">Afghanistan</option> <option value="Albania">Albania</option> <option value="Algeria">Algeria</option> <option value="American Samoa">American Samoa</option> <option value="Andorra">Andorra</option> <option value="Angola">Angola</option> <option value="Anguilla">Anguilla</option> <option value="Antigua and Barbuda">Antigua and Barbuda</option> <option value="Argentina">Argentina</option> <option value="Armenia">Armenia</option> <option value="Aruba">Aruba</option> <option value="Australia">Australia</option> <option value="Austria">Austria</option> <option value="Azerbaijan">Azerbaijan</option> <option value="The Bahamas">The Bahamas</option> <option value="Bahrain">Bahrain</option> <option value="Bangladesh">Bangladesh</option> <option value="Barbados">Barbados</option> <option value="Belarus">Belarus</option> <option value="Belgium">Belgium</option> <option value="Belize">Belize</option> <option value="Benin">Benin</option> <option value="Bermuda">Bermuda</option> <option value="Bhutan">Bhutan</option> <option value="Bolivia">Bolivia</option> <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option> <option value="Botswana">Botswana</option> <option value="Brazil">Brazil</option> <option value="Brunei">Brunei</option> <option value="Bulgaria">Bulgaria</option> <option value="Burkina Faso">Burkina Faso</option> <option value="Burundi">Burundi</option> <option value="Cambodia">Cambodia</option> <option value="Cameroon">Cameroon</option> <option value="Canada">Canada</option> <option value="Cape Verde">Cape Verde</option> <option value="Cayman Islands">Cayman Islands</option> <option value="Central African Republic">Central African Republic</option> <option value="Chad">Chad</option> <option value="Chile">Chile</option> <option value="China">China</option> <option value="Christmas Island">Christmas Island</option> <option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option> <option value="Colombia">Colombia</option> <option value="Comoros">Comoros</option> <option value="Congo">Congo</option> <option value="Cook Islands">Cook Islands</option> <option value="Costa Rica">Costa Rica</option> <option value="Cote d'Ivoire">Cote d'Ivoire</option> <option value="Croatia">Croatia</option> <option value="Cuba">Cuba</option> <option value="Cura莽ao">Cura莽ao</option> <option value="Cyprus">Cyprus</option> <option value="Czech Republic">Czech Republic</option> <option value="Democratic Republic of the Congo">Democratic Republic of the Congo</option> <option value="Denmark">Denmark</option> <option value="Djibouti">Djibouti</option> <option value="Dominica">Dominica</option> <option value="Dominican Republic">Dominican Republic</option> <option value="Ecuador">Ecuador</option> <option value="Egypt">Egypt</option> <option value="El Salvador">El Salvador</option> <option value="Equatorial Guinea">Equatorial Guinea</option> <option value="Eritrea">Eritrea</option> <option value="Estonia">Estonia</option> <option value="Ethiopia">Ethiopia</option> <option value="Falkland Islands">Falkland Islands</option> <option value="Faroe Islands">Faroe Islands</option> <option value="Fiji">Fiji</option> <option value="Finland">Finland</option> <option value="France">France</option> <option value="French Polynesia">French Polynesia</option> <option value="Gabon">Gabon</option> <option value="The Gambia">The Gambia</option> <option value="Georgia">Georgia</option> <option value="Germany">Germany</option> <option value="Ghana">Ghana</option> <option value="Gibraltar">Gibraltar</option> <option value="Greece">Greece</option> <option value="Greenland">Greenland</option> <option value="Grenada">Grenada</option> <option value="Guadeloupe">Guadeloupe</option> <option value="Guam">Guam</option> <option value="Guatemala">Guatemala</option> <option value="Guernsey">Guernsey</option> <option value="Guinea">Guinea</option> <option value="Guinea-Bissau">Guinea-Bissau</option> <option value="Guyana">Guyana</option> <option value="Haiti">Haiti</option> <option value="Honduras">Honduras</option> <option value="Hong Kong">Hong Kong</option> <option value="Hungary">Hungary</option> <option value="Iceland">Iceland</option> <option value="India">India</option> <option value="Indonesia">Indonesia</option> <option value="Iran">Iran</option> <option value="Iraq">Iraq</option> <option value="Ireland">Ireland</option> <option value="Israel">Israel</option> <option value="Italy">Italy</option> <option value="Jamaica">Jamaica</option> <option value="Japan">Japan</option> <option value="Jersey">Jersey</option> <option value="Jordan">Jordan</option> <option value="Kazakhstan">Kazakhstan</option> <option value="Kenya">Kenya</option> <option value="Kiribati">Kiribati</option> <option value="North Korea">North Korea</option> <option value="South Korea">South Korea</option> <option value="Kosovo">Kosovo</option> <option value="Kuwait">Kuwait</option> <option value="Kyrgyzstan">Kyrgyzstan</option> <option value="Laos">Laos</option> <option value="Latvia">Latvia</option> <option value="Lebanon">Lebanon</option> <option value="Lesotho">Lesotho</option> <option value="Liberia">Liberia</option> <option value="Libya">Libya</option> <option value="Liechtenstein">Liechtenstein</option> <option value="Lithuania">Lithuania</option> <option value="Luxembourg">Luxembourg</option> <option value="Macau">Macau</option> <option value="Macedonia">Macedonia</option> <option value="Madagascar">Madagascar</option> <option value="Malawi">Malawi</option> <option value="Malaysia">Malaysia</option> <option value="Maldives">Maldives</option> <option value="Mali">Mali</option> <option value="Malta">Malta</option> <option value="Marshall Islands">Marshall Islands</option> <option value="Martinique">Martinique</option> <option value="Mauritania">Mauritania</option> <option value="Mauritius">Mauritius</option> <option value="Mayotte">Mayotte</option> <option value="Mexico">Mexico</option> <option value="Micronesia">Micronesia</option> <option value="Moldova">Moldova</option> <option value="Monaco">Monaco</option> <option value="Mongolia">Mongolia</option> <option value="Montenegro">Montenegro</option> <option value="Montserrat">Montserrat</option> <option value="Morocco">Morocco</option> <option value="Mozambique">Mozambique</option> <option value="Myanmar">Myanmar</option> <option value="Nagorno-Karabakh">Nagorno-Karabakh</option> <option value="Namibia">Namibia</option> <option value="Nauru">Nauru</option> <option value="Nepal">Nepal</option> <option value="Netherlands">Netherlands</option> <option value="Netherlands Antilles">Netherlands Antilles</option> <option value="New Caledonia">New Caledonia</option> <option value="New Zealand">New Zealand</option> <option value="Nicaragua">Nicaragua</option> <option value="Niger">Niger</option> <option value="Nigeria">Nigeria</option> <option value="Niue">Niue</option> <option value="Norfolk Island">Norfolk Island</option> <option value="Turkish Republic of Northern Cyprus">Turkish Republic of Northern Cyprus</option> <option value="Northern Mariana">Northern Mariana</option> <option value="Norway">Norway</option> <option value="Oman">Oman</option> <option value="Pakistan">Pakistan</option> <option value="Palau">Palau</option> <option value="Palestine">Palestine</option> <option value="Panama">Panama</option> <option value="Papua New Guinea">Papua New Guinea</option> <option value="Paraguay">Paraguay</option> <option value="Peru">Peru</option> <option value="Philippines">Philippines</option> <option value="Pitcairn Islands">Pitcairn Islands</option> <option value="Poland">Poland</option> <option value="Portugal">Portugal</option> <option value="Puerto Rico">Puerto Rico</option> <option value="Qatar">Qatar</option> <option value="Republic of the Congo">Republic of the Congo</option> <option value="Romania">Romania</option> <option value="Russia">Russia</option> <option value="Rwanda">Rwanda</option> <option value="Saint Barthelemy">Saint Barthelemy</option> <option value="Saint Helena">Saint Helena</option> <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option> <option value="Saint Lucia">Saint Lucia</option> <option value="Saint Martin">Saint Martin</option> <option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option> <option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option> <option value="Samoa">Samoa</option> <option value="San Marino">San Marino</option> <option value="Sao Tome and Principe">Sao Tome and Principe</option> <option value="Saudi Arabia">Saudi Arabia</option> <option value="Senegal">Senegal</option> <option value="Serbia">Serbia</option> <option value="Seychelles">Seychelles</option> <option value="Sierra Leone">Sierra Leone</option> <option value="Singapore">Singapore</option> <option value="Slovakia">Slovakia</option> <option value="Slovenia">Slovenia</option> <option value="Solomon Islands">Solomon Islands</option> <option value="Somalia">Somalia</option> <option value="Somaliland">Somaliland</option> <option value="South Africa">South Africa</option> <option value="South Ossetia">South Ossetia</option> <option value="South Sudan">South Sudan</option> <option value="Spain">Spain</option> <option value="Sri Lanka">Sri Lanka</option> <option value="Sudan">Sudan</option> <option value="Suriname">Suriname</option> <option value="Svalbard">Svalbard</option> <option value="eSwatini">eSwatini</option> <option value="Sweden">Sweden</option> <option value="Switzerland">Switzerland</option> <option value="Syria">Syria</option> <option value="Taiwan">Taiwan</option> <option value="Tajikistan">Tajikistan</option> <option value="Tanzania">Tanzania</option> <option value="Thailand">Thailand</option> <option value="Timor-Leste">Timor-Leste</option> <option value="Togo">Togo</option> <option value="Tokelau">Tokelau</option> <option value="Tonga">Tonga</option> <option value="Transnistria Pridnestrovie">Transnistria Pridnestrovie</option> <option value="Trinidad and Tobago">Trinidad and Tobago</option> <option value="Tristan da Cunha">Tristan da Cunha</option> <option value="Tunisia">Tunisia</option> <option value="Turkey">Turkey</option> <option value="Turkmenistan">Turkmenistan</option> <option value="Turks and Caicos Islands">Turks and Caicos Islands</option> <option value="Tuvalu">Tuvalu</option> <option value="Uganda">Uganda</option> <option value="Ukraine">Ukraine</option> <option value="United Arab Emirates">United Arab Emirates</option> <option value="United Kingdom">United Kingdom</option> <option value="United States">United States</option> <option value="Uruguay">Uruguay</option> <option value="Uzbekistan">Uzbekistan</option> <option value="Vanuatu">Vanuatu</option> <option value="Vatican City">Vatican City</option> <option value="Venezuela">Venezuela</option> <option value="Vietnam">Vietnam</option> <option value="British Virgin Islands">British Virgin Islands</option> <option value="Isle of Man">Isle of Man</option> <option value="US Virgin Islands">US Virgin Islands</option> <option value="Wallis and Futuna">Wallis and Futuna</option> <option value="Western Sahara">Western Sahara</option> <option value="Yemen">Yemen</option> <option value="Zambia">Zambia</option> <option value="Zimbabwe">Zimbabwe</option> <option value="other">Other</option> </select><label class="form-sub-label" for="input_56_country" id="sublabel_56_country" style="min-height:13px">Country</label></span></span></div> </div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_15"><label class="form-label form-label-left form-label-auto" id="label_15" aria-hidden="false"> Service Area<span class="form-required">*</span> </label> <div id="cid_15" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_15" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_15" type="checkbox" class="form-checkbox validate[required]" id="input_15_0" name="q15_serviceArea[]" required="" value="Local (within limits of local jurisdiction)" /><label id="label_input_15_0" for="input_15_0">Local (within limits of local jurisdiction)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_15" type="checkbox" class="form-checkbox validate[required]" id="input_15_1" name="q15_serviceArea[]" required="" value="County (within county limits)" /><label id="label_input_15_1" for="input_15_1">County (within county limits)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_15" type="checkbox" class="form-checkbox validate[required]" id="input_15_2" name="q15_serviceArea[]" required="" value="Multi-County (between multiple counties but not the whole state)" /><label id="label_input_15_2" for="input_15_2">Multi-County (between multiple counties but not the whole state)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_15" type="checkbox" class="form-checkbox validate[required]" id="input_15_3" name="q15_serviceArea[]" required="" value="Statewide (within state borders)" /><label id="label_input_15_3" for="input_15_3">Statewide (within state borders)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_15" type="checkbox" class="form-checkbox validate[required]" id="input_15_4" name="q15_serviceArea[]" required="" value="Multi-State (between multiple states but not nationwide)" /><label id="label_input_15_4" for="input_15_4">Multi-State (between multiple states but not nationwide)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_15" type="checkbox" class="form-checkbox validate[required]" id="input_15_5" name="q15_serviceArea[]" required="" value="National (available across the U.S. and territories, including tribal lands)" /><label id="label_input_15_5" for="input_15_5">National (available across the U.S. and territories, including tribal lands)</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_85"><label class="form-label form-label-left form-label-auto" id="label_85" aria-hidden="false"> Does the organization/program operate a hotline?<span class="form-required">*</span> </label> <div id="cid_85" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_85" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_85" type="radio" class="form-radio validate[required]" id="input_85_0" name="q85_doesThe85" required="" value="Yes" /><label id="label_input_85_0" for="input_85_0">Yes</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_85" type="radio" class="form-radio validate[required]" id="input_85_1" name="q85_doesThe85" required="" value="No" /><label id="label_input_85_1" for="input_85_1">No</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_17"><label class="form-label form-label-left form-label-auto" id="label_17" aria-hidden="false"> If yes, what signal types can be used to access hotline services? (Select all that apply)<span class="form-required">*</span> </label> <div id="cid_17" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_17" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_17" type="checkbox" class="form-checkbox validate[required]" id="input_17_0" name="q17_ifYes[]" required="" value="Calls" /><label id="label_input_17_0" for="input_17_0">Calls</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_17" type="checkbox" class="form-checkbox validate[required]" id="input_17_1" name="q17_ifYes[]" required="" value="Text Messages/SMS" /><label id="label_input_17_1" for="input_17_1">Text Messages/SMS</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_17" type="checkbox" class="form-checkbox validate[required]" id="input_17_2" name="q17_ifYes[]" required="" value="Web Chat" /><label id="label_input_17_2" for="input_17_2">Web Chat</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_17" type="checkbox" class="form-checkbox validate[required]" id="input_17_3" name="q17_ifYes[]" required="" value="Email" /><label id="label_input_17_3" for="input_17_3">Email</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_17" type="checkbox" class="form-checkbox validate[required]" id="input_17_4" name="q17_ifYes[]" required="" value="Not Applicable" /><label id="label_input_17_4" for="input_17_4">Not Applicable</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_86"><label class="form-label form-label-left form-label-auto" id="label_86" aria-hidden="false"> Hours of Operation<span class="form-required">*</span> </label> <div id="cid_86" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_86" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_86" type="radio" class="form-radio validate[required]" id="input_86_0" name="q86_hoursOf86" required="" value="Program Open 24 hours/day" /><label id="label_input_86_0" for="input_86_0">Program Open 24 hours/day</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_86" type="radio" class="form-radio validate[required]" id="input_86_1" name="q86_hoursOf86" required="" value="Program Not Open 24 hours/day" /><label id="label_input_86_1" for="input_86_1">Program Not Open 24 hours/day</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_time" id="id_60"><label class="form-label form-label-left form-label-auto" id="label_60" for="input_60_hourSelect" aria-hidden="false"> If your program is open 24 hours/day, please input a 24-hour range (e.g. 12:00 AM Until 12:00 AM).<span class="form-required">*</span> </label> <div id="cid_60" class="form-input jf-required"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top"><select class="time-dropdown form-dropdown validate[required, time]" id="input_60_hourSelect" name="q60_ifYour[hourSelect]" data-component="time-hour" required="" aria-labelledby="label_60 sublabel_60_hour"> <option></option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> </select><span class="date-separate">聽:</span><label class="form-sub-label" for="input_60_hourSelect" id="sublabel_60_hour" style="min-height:13px">Hour</label></span><span class="form-sub-label-container" style="vertical-align:top"><select class="time-dropdown form-dropdown validate[required]" id="input_60_minuteSelect" name="q60_ifYour[minuteSelect]" data-component="time-minute" required="" aria-labelledby="label_60 sublabel_60_minutes"> <option></option> <option value="00">00</option> <option value="10">10</option> <option value="20">20</option> <option value="30">30</option> <option value="40">40</option> <option value="50">50</option> </select><label class="form-sub-label" for="input_60_minuteSelect" id="sublabel_60_minutes" style="min-height:13px">Minutes</label></span><span class="form-sub-label-container" style="vertical-align:top"><select class="time-dropdown form-dropdown validate[required]" id="input_60_ampm" name="q60_ifYour[ampm]" data-component="time-ampm" required="" aria-labelledby="label_60 sublabel_60_ampm"> <option value="AM" selected="">AM</option> <option value="PM">PM</option> </select><label class="form-sub-label" for="input_60_ampm" id="sublabel_60_ampm" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap">AM/PM Option</label></span><span class="form-sub-label-container until-wrapper" style="vertical-align:top"> <div id="until_60" class="until-text"> Until</div><label class="form-sub-label" for="until_60" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap">until</label> </span><span class="form-sub-label-container" style="vertical-align:top"><select class="time-dropdown form-dropdown validate[required]" id="input_60_hourSelectRange" name="q60_ifYour[hourSelectRange]" data-component="time-hour-range" required="" aria-labelledby="label_60 sublabel_60_hourRange"> <option></option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option> </select><span class="date-separate">聽:</span><label class="form-sub-label" for="input_60_hourSelectRange" id="sublabel_60_hourRange" style="min-height:13px">Hour</label></span><span class="form-sub-label-container" style="vertical-align:top"><select class="time-dropdown form-dropdown validate[required]" id="input_60_minuteSelectRange" name="q60_ifYour[minuteSelectRange]" data-component="time-minute-range" required="" aria-labelledby="label_60 sublabel_60_minutesRange"> <option></option> <option value="00">00</option> <option value="10">10</option> <option value="20">20</option> <option value="30">30</option> <option value="40">40</option> <option value="50">50</option> </select><label class="form-sub-label" for="input_60_minuteSelectRange" id="sublabel_60_minutesRange" style="min-height:13px">Minutes</label></span><span class="form-sub-label-container" style="vertical-align:top"><select class="time-dropdown form-dropdown validate[required]" id="input_60_ampmRange" name="q60_ifYour[ampmRange]" data-component="time-ampm-range" required="" aria-labelledby="label_60 sublabel_60_ampmRange"> <option value="AM" selected="">AM</option> <option value="PM">PM</option> </select><label class="form-sub-label" for="input_60_ampmRange" id="sublabel_60_ampmRange" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap">AM/PM Option</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_87"><label class="form-label form-label-left form-label-auto" id="label_87" aria-hidden="false"> Does the organization have and maintain a policy to protect the identity and information of the victims they serve?<span class="form-required">*</span> </label> <div id="cid_87" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_87" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_87" type="radio" class="form-radio validate[required]" id="input_87_0" name="q87_doesThe" required="" value="Yes" /><label id="label_input_87_0" for="input_87_0">Yes</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_87" type="radio" class="form-radio validate[required]" id="input_87_1" name="q87_doesThe" required="" value="No" /><label id="label_input_87_1" for="input_87_1">No</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_20"><label class="form-label form-label-left form-label-auto" id="label_20" aria-hidden="false"> Crime Types聽(Select all that apply)<span class="form-required">*</span> </label> <div id="cid_20" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_20" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_0" name="q20_crimeTypesselect[]" required="" value="All Crime Types" /><label id="label_input_20_0" for="input_20_0">All Crime Types</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_1" name="q20_crimeTypesselect[]" required="" value="Arson" /><label id="label_input_20_1" for="input_20_1">Arson</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_2" name="q20_crimeTypesselect[]" required="" value="Assault" /><label id="label_input_20_2" for="input_20_2">Assault</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_3" name="q20_crimeTypesselect[]" required="" value="Bullying" /><label id="label_input_20_3" for="input_20_3">Bullying</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_4" name="q20_crimeTypesselect[]" required="" value="Child Exposed to Violence" /><label id="label_input_20_4" for="input_20_4">Child Exposed to Violence</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_5" name="q20_crimeTypesselect[]" required="" value="Child Physical Abuse or Neglect (Current or Recent)" /><label id="label_input_20_5" for="input_20_5">Child Physical Abuse or Neglect (Current or Recent)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_6" name="q20_crimeTypesselect[]" required="" value="Child Physical Abuse or Neglect (Historical)" /><label id="label_input_20_6" for="input_20_6">Child Physical Abuse or Neglect (Historical)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_7" name="q20_crimeTypesselect[]" required="" value="Child Sexual Abuse Images" /><label id="label_input_20_7" for="input_20_7">Child Sexual Abuse Images</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_8" name="q20_crimeTypesselect[]" required="" value="Child Sexual Abuse (Current or Recent)" /><label id="label_input_20_8" for="input_20_8">Child Sexual Abuse (Current or Recent)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_9" name="q20_crimeTypesselect[]" required="" value="Child Sexual Abuse (Historical)" /><label id="label_input_20_9" for="input_20_9">Child Sexual Abuse (Historical)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_10" name="q20_crimeTypesselect[]" required="" value="Cyber Crimes" /><label id="label_input_20_10" for="input_20_10">Cyber Crimes</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_11" name="q20_crimeTypesselect[]" required="" value="Domestic Violence (Intimate Partner)" /><label id="label_input_20_11" for="input_20_11">Domestic Violence (Intimate Partner)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_12" name="q20_crimeTypesselect[]" required="" value="Domestic Violence (Non-Intimate Partner)" /><label id="label_input_20_12" for="input_20_12">Domestic Violence (Non-Intimate Partner)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_13" name="q20_crimeTypesselect[]" required="" value="Driving Under the Influence" /><label id="label_input_20_13" for="input_20_13">Driving Under the Influence</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_14" name="q20_crimeTypesselect[]" required="" value="Elder Abuse or Neglect" /><label id="label_input_20_14" for="input_20_14">Elder Abuse or Neglect</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_15" name="q20_crimeTypesselect[]" required="" value="Financial Crimes/Fraud/Identity Theft" /><label id="label_input_20_15" for="input_20_15">Financial Crimes/Fraud/Identity Theft</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_16" name="q20_crimeTypesselect[]" required="" value="Gang Violence" /><label id="label_input_20_16" for="input_20_16">Gang Violence</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_17" name="q20_crimeTypesselect[]" required="" value="Hate Crime" /><label id="label_input_20_17" for="input_20_17">Hate Crime</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_18" name="q20_crimeTypesselect[]" required="" value="Harassment" /><label id="label_input_20_18" for="input_20_18">Harassment</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_19" name="q20_crimeTypesselect[]" required="" value="Homicide" /><label id="label_input_20_19" for="input_20_19">Homicide</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_20" name="q20_crimeTypesselect[]" required="" value="Human Trafficking (Labor)" /><label id="label_input_20_20" for="input_20_20">Human Trafficking (Labor)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_21" name="q20_crimeTypesselect[]" required="" value="Human Trafficking (Sex)" /><label id="label_input_20_21" for="input_20_21">Human Trafficking (Sex)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_22" name="q20_crimeTypesselect[]" required="" value="Kidnapping (Custodial/Familial)" /><label id="label_input_20_22" for="input_20_22">Kidnapping (Custodial/Familial)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_23" name="q20_crimeTypesselect[]" required="" value="Kidnapping (Non-Custodial)" /><label id="label_input_20_23" for="input_20_23">Kidnapping (Non-Custodial)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_24" name="q20_crimeTypesselect[]" required="" value="Non-Consensual Pornography" /><label id="label_input_20_24" for="input_20_24">Non-Consensual Pornography</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_25" name="q20_crimeTypesselect[]" required="" value="Robbery/Theft/Burglary" /><label id="label_input_20_25" for="input_20_25">Robbery/Theft/Burglary</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_26" name="q20_crimeTypesselect[]" required="" value="Sexual Assault" /><label id="label_input_20_26" for="input_20_26">Sexual Assault</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_27" name="q20_crimeTypesselect[]" required="" value="Stalking" /><label id="label_input_20_27" for="input_20_27">Stalking</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_28" name="q20_crimeTypesselect[]" required="" value="Teen Dating Violence" /><label id="label_input_20_28" for="input_20_28">Teen Dating Violence</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_29" name="q20_crimeTypesselect[]" required="" value="Terrorism and Mass Violence" /><label id="label_input_20_29" for="input_20_29">Terrorism and Mass Violence</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_30" name="q20_crimeTypesselect[]" required="" value="Violation of a Court (Protective) Order" /><label id="label_input_20_30" for="input_20_30">Violation of a Court (Protective) Order</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_20" type="checkbox" class="form-checkbox validate[required]" id="input_20_31" name="q20_crimeTypesselect[]" required="" value="Other" /><label id="label_input_20_31" for="input_20_31">Other</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_22"><label class="form-label form-label-left form-label-auto" id="label_22" aria-hidden="false"> Services Provided聽(Select all that apply)<span class="form-required">*</span> </label> <div id="cid_22" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_22" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_0" name="q22_servicesProvidedselect[]" required="" value="Batterer Education/Batterer Intervention" /><label id="label_input_22_0" for="input_22_0">Batterer Education/Batterer Intervention</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_1" name="q22_servicesProvidedselect[]" required="" value="Case Management/Advocacy" /><label id="label_input_22_1" for="input_22_1">Case Management/Advocacy</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_2" name="q22_servicesProvidedselect[]" required="" value="Children/Youth/Family Services" /><label id="label_input_22_2" for="input_22_2">Children/Youth/Family Services</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_3" name="q22_servicesProvidedselect[]" required="" value="Counseling/Mental Health/Emotional Support" /><label id="label_input_22_3" for="input_22_3">Counseling/Mental Health/Emotional Support</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_4" name="q22_servicesProvidedselect[]" required="" value="Crime Reporting" /><label id="label_input_22_4" for="input_22_4">Crime Reporting</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_5" name="q22_servicesProvidedselect[]" required="" value="Crisis Intervention/Crisis Response" /><label id="label_input_22_5" for="input_22_5">Crisis Intervention/Crisis Response</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_6" name="q22_servicesProvidedselect[]" required="" value="Domestic Violence Urgent/Acute Response" /><label id="label_input_22_6" for="input_22_6">Domestic Violence Urgent/Acute Response</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_7" name="q22_servicesProvidedselect[]" required="" value="Employment/Education Assistance" /><label id="label_input_22_7" for="input_22_7">Employment/Education Assistance</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_8" name="q22_servicesProvidedselect[]" required="" value="Financial or Material Assistance" /><label id="label_input_22_8" for="input_22_8">Financial or Material Assistance</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_9" name="q22_servicesProvidedselect[]" required="" value="Forensic Services" /><label id="label_input_22_9" for="input_22_9">Forensic Services</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_10" name="q22_servicesProvidedselect[]" required="" value="General Social Services" /><label id="label_input_22_10" for="input_22_10">General Social Services</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_11" name="q22_servicesProvidedselect[]" required="" value="Hotline/Information and Referrals" /><label id="label_input_22_11" for="input_22_11">Hotline/Information and Referrals</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_12" name="q22_servicesProvidedselect[]" required="" value="Housing Emergency/Short-Term" /><label id="label_input_22_12" for="input_22_12">Housing Emergency/Short-Term</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_13" name="q22_servicesProvidedselect[]" required="" value="Housing (Long-Term/Transitional)" /><label id="label_input_22_13" for="input_22_13">Housing (Long-Term/Transitional)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_14" name="q22_servicesProvidedselect[]" required="" value="Identity Theft Recovery" /><label id="label_input_22_14" for="input_22_14">Identity Theft Recovery</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_15" name="q22_servicesProvidedselect[]" required="" value="Legal/Justice System Assistance (Civil)" /><label id="label_input_22_15" for="input_22_15">Legal/Justice System Assistance (Civil)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_16" name="q22_servicesProvidedselect[]" required="" value="Legal/Justice System Assistance (Criminal)" /><label id="label_input_22_16" for="input_22_16">Legal/Justice System Assistance (Criminal)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_17" name="q22_servicesProvidedselect[]" required="" value="Medical/Health Assistance" /><label id="label_input_22_17" for="input_22_17">Medical/Health Assistance</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_18" name="q22_servicesProvidedselect[]" required="" value="Safety Planning" /><label id="label_input_22_18" for="input_22_18">Safety Planning</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_19" name="q22_servicesProvidedselect[]" required="" value="Sexual Assault/Rape Urgent/Acute Response" /><label id="label_input_22_19" for="input_22_19">Sexual Assault/Rape Urgent/Acute Response</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_20" name="q22_servicesProvidedselect[]" required="" value="Support Groups" /><label id="label_input_22_20" for="input_22_20">Support Groups</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_21" name="q22_servicesProvidedselect[]" required="" value="Traditional Healing and Referrals" /><label id="label_input_22_21" for="input_22_21">Traditional Healing and Referrals</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_22" name="q22_servicesProvidedselect[]" required="" value="Transportation Assistance (Local)" /><label id="label_input_22_22" for="input_22_22">Transportation Assistance (Local)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_23" name="q22_servicesProvidedselect[]" required="" value="Transportation Assistance (Relocation)" /><label id="label_input_22_23" for="input_22_23">Transportation Assistance (Relocation)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_24" name="q22_servicesProvidedselect[]" required="" value="Victim Rights Advocacy (Non-direct)" /><label id="label_input_22_24" for="input_22_24">Victim Rights Advocacy (Non-direct)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_22" type="checkbox" class="form-checkbox validate[required]" id="input_22_25" name="q22_servicesProvidedselect[]" required="" value="Other" /><label id="label_input_22_25" for="input_22_25">Other</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_23"><label class="form-label form-label-left form-label-auto" id="label_23" aria-hidden="false"> Fees/Cost of Services聽(Select all that apply)<span class="form-required">*</span> </label> <div id="cid_23" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_23" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_23" type="checkbox" class="form-checkbox validate[required]" id="input_23_0" name="q23_feescostOf[]" required="" value="Free" /><label id="label_input_23_0" for="input_23_0">Free</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_23" type="checkbox" class="form-checkbox validate[required]" id="input_23_1" name="q23_feescostOf[]" required="" value="Sliding Scale" /><label id="label_input_23_1" for="input_23_1">Sliding Scale</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_23" type="checkbox" class="form-checkbox validate[required]" id="input_23_2" name="q23_feescostOf[]" required="" value="Set Program/Session/Case Fee" /><label id="label_input_23_2" for="input_23_2">Set Program/Session/Case Fee</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_23" type="checkbox" class="form-checkbox validate[required]" id="input_23_3" name="q23_feescostOf[]" required="" value="Accepts Insurance" /><label id="label_input_23_3" for="input_23_3">Accepts Insurance</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_24"><label class="form-label form-label-left form-label-auto" id="label_24" aria-hidden="false"> Service Access Method(s) (Select all that apply)<span class="form-required">*</span> </label> <div id="cid_24" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_24" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_24" type="checkbox" class="form-checkbox validate[required]" id="input_24_0" name="q24_serviceAccess[]" required="" value="Call" /><label id="label_input_24_0" for="input_24_0">Call</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_24" type="checkbox" class="form-checkbox validate[required]" id="input_24_1" name="q24_serviceAccess[]" required="" value="Web Chat" /><label id="label_input_24_1" for="input_24_1">Web Chat</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_24" type="checkbox" class="form-checkbox validate[required]" id="input_24_2" name="q24_serviceAccess[]" required="" value="Email" /><label id="label_input_24_2" for="input_24_2">Email</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_24" type="checkbox" class="form-checkbox validate[required]" id="input_24_3" name="q24_serviceAccess[]" required="" value="Text Message/SMS" /><label id="label_input_24_3" for="input_24_3">Text Message/SMS</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_24" type="checkbox" class="form-checkbox validate[required]" id="input_24_4" name="q24_serviceAccess[]" required="" value="Walk-in" /><label id="label_input_24_4" for="input_24_4">Walk-in</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_24" type="checkbox" class="form-checkbox validate[required]" id="input_24_5" name="q24_serviceAccess[]" required="" value="Web Form" /><label id="label_input_24_5" for="input_24_5">Web Form</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_88"><label class="form-label form-label-left form-label-auto" id="label_88" aria-hidden="false"> Does your organization/program have an intake process?<span class="form-required">*</span> </label> <div id="cid_88" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_88" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_88" type="radio" class="form-radio validate[required]" id="input_88_0" name="q88_doesYour" required="" value="Yes" /><label id="label_input_88_0" for="input_88_0">Yes</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_88" type="radio" class="form-radio validate[required]" id="input_88_1" name="q88_doesYour" required="" value="No" /><label id="label_input_88_1" for="input_88_1">No</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_textarea" id="id_66"><label class="form-label form-label-left form-label-auto" id="label_66" for="input_66" aria-hidden="false"> If Yes, please describe your intake process below.<span class="form-required">*</span> </label> <div id="cid_66" class="form-input jf-required"> <textarea id="input_66" class="form-textarea validate[required]" name="q66_ifYes66" cols="40" rows="6" data-component="textarea" required="" aria-labelledby="label_66"></textarea> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_28"><label class="form-label form-label-left form-label-auto" id="label_28" aria-hidden="false"> Ages Groups Served聽(Select all that apply)<span class="form-required">*</span> </label> <div id="cid_28" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_28" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_28" type="checkbox" class="form-checkbox validate[required]" id="input_28_0" name="q28_agesGroups[]" required="" value="Minors (Under 18)" /><label id="label_input_28_0" for="input_28_0">Minors (Under 18)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_28" type="checkbox" class="form-checkbox validate[required]" id="input_28_1" name="q28_agesGroups[]" required="" value="Adults" /><label id="label_input_28_1" for="input_28_1">Adults</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_89"><label class="form-label form-label-left form-label-auto" id="label_89" aria-hidden="false"> Parent/Guardian Consent Required for Minors?<span class="form-required">*</span> </label> <div id="cid_89" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_89" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_89" type="radio" class="form-radio validate[required]" id="input_89_0" name="q89_parentguardianConsent89" required="" value="Yes" /><label id="label_input_89_0" for="input_89_0">Yes</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_89" type="radio" class="form-radio validate[required]" id="input_89_1" name="q89_parentguardianConsent89" required="" value="No" /><label id="label_input_89_1" for="input_89_1">No</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_30"><label class="form-label form-label-left form-label-auto" id="label_30" aria-hidden="false"> Genders Served聽(Select all that apply)<span class="form-required">*</span> </label> <div id="cid_30" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_30" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_30" type="checkbox" class="form-checkbox validate[required]" id="input_30_0" name="q30_gendersServedselect[]" required="" value="Female" /><label id="label_input_30_0" for="input_30_0">Female</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_30" type="checkbox" class="form-checkbox validate[required]" id="input_30_1" name="q30_gendersServedselect[]" required="" value="Male" /><label id="label_input_30_1" for="input_30_1">Male</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_30" type="checkbox" class="form-checkbox validate[required]" id="input_30_2" name="q30_gendersServedselect[]" required="" value="Transgender Male" /><label id="label_input_30_2" for="input_30_2">Transgender Male</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_30" type="checkbox" class="form-checkbox validate[required]" id="input_30_3" name="q30_gendersServedselect[]" required="" value="Transgender Female" /><label id="label_input_30_3" for="input_30_3">Transgender Female</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_30" type="checkbox" class="form-checkbox validate[required]" id="input_30_4" name="q30_gendersServedselect[]" required="" value="Gender Non-binary" /><label id="label_input_30_4" for="input_30_4">Gender Non-binary</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_30" type="checkbox" class="form-checkbox validate[required]" id="input_30_5" name="q30_gendersServedselect[]" required="" value="Gender Non-conforming" /><label id="label_input_30_5" for="input_30_5">Gender Non-conforming</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_30" type="checkbox" class="form-checkbox validate[required]" id="input_30_6" name="q30_gendersServedselect[]" required="" value="All Gender Identities" /><label id="label_input_30_6" for="input_30_6">All Gender Identities</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_32"><label class="form-label form-label-left form-label-auto" id="label_32" aria-hidden="false"> Specialized Programming/Services聽(Select all that apply)<span class="form-required">*</span> </label> <div id="cid_32" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_32" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_0" name="q32_specializedProgrammingservicesselect[]" required="" value="Veterans/Military" /><label id="label_input_32_0" for="input_32_0">Veterans/Military</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_1" name="q32_specializedProgrammingservicesselect[]" required="" value="Elders (60+)" /><label id="label_input_32_1" for="input_32_1">Elders (60+)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_2" name="q32_specializedProgrammingservicesselect[]" required="" value="LGBTQIA+/Two-Spirit Persons" /><label id="label_input_32_2" for="input_32_2">LGBTQIA+/Two-Spirit Persons</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_3" name="q32_specializedProgrammingservicesselect[]" required="" value="Deaf/Hard of Hearing" /><label id="label_input_32_3" for="input_32_3">Deaf/Hard of Hearing</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_4" name="q32_specializedProgrammingservicesselect[]" required="" value="Persons with Disabilities" /><label id="label_input_32_4" for="input_32_4">Persons with Disabilities</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_5" name="q32_specializedProgrammingservicesselect[]" required="" value="Immigrants/Migrants" /><label id="label_input_32_5" for="input_32_5">Immigrants/Migrants</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_6" name="q32_specializedProgrammingservicesselect[]" required="" value="People without Housing" /><label id="label_input_32_6" for="input_32_6">People without Housing</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_7" name="q32_specializedProgrammingservicesselect[]" required="" value="Campus" /><label id="label_input_32_7" for="input_32_7">Campus</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_8" name="q32_specializedProgrammingservicesselect[]" required="" value="No specialized programming/services" /><label id="label_input_32_8" for="input_32_8">No specialized programming/services</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_32" type="checkbox" class="form-checkbox validate[required]" id="input_32_9" name="q32_specializedProgrammingservicesselect[]" required="" value="Other" /><label id="label_input_32_9" for="input_32_9">Other</label></span></div> </div> </li> <li class="form-line" data-type="control_textbox" id="id_95"><label class="form-label form-label-left form-label-auto" id="label_95" for="input_95" aria-hidden="true"> </label> <div id="cid_95" class="form-input"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_95" name="q95_input95" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_95 sublabel_input_95" value="" /><label class="form-sub-label" for="input_95" id="sublabel_input_95" style="min-height:13px">If you selected other, please write a short sentence about your specialized programming/services.</label></span> </div> </li> <li class="form-line jf-required" data-type="control_checkbox" id="id_35"><label class="form-label form-label-left form-label-auto" id="label_35" aria-hidden="false"> Staff Language Skills聽(Select all that apply)<span class="form-required">*</span> </label> <div id="cid_35" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_35" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_35" type="checkbox" class="form-checkbox validate[required]" id="input_35_0" name="q35_staffLanguage[]" required="" value="English" /><label id="label_input_35_0" for="input_35_0">English</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_35" type="checkbox" class="form-checkbox validate[required]" id="input_35_1" name="q35_staffLanguage[]" required="" value="Spanish" /><label id="label_input_35_1" for="input_35_1">Spanish</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_35" type="checkbox" class="form-checkbox validate[required]" id="input_35_2" name="q35_staffLanguage[]" required="" value="American Sign Language" /><label id="label_input_35_2" for="input_35_2">American Sign Language</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_35" type="checkbox" class="form-checkbox validate[required]" id="input_35_3" name="q35_staffLanguage[]" required="" value="Other" /><label id="label_input_35_3" for="input_35_3">Other</label></span></div> </div> </li> <li class="form-line" data-type="control_textbox" id="id_93"><label class="form-label form-label-left form-label-auto" id="label_93" for="input_93" aria-hidden="true"> </label> <div id="cid_93" class="form-input"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_93" name="q93_input93" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_93 sublabel_input_93" value="" /><label class="form-sub-label" for="input_93" id="sublabel_input_93" style="min-height:13px">If you selected other, please write in the language(s).</label></span> </div> </li> <li class="form-line jf-required" data-type="control_radio" id="id_90"><label class="form-label form-label-left form-label-auto" id="label_90" aria-hidden="false"> Do you have access to interpretation services?<span class="form-required">*</span> </label> <div id="cid_90" class="form-input jf-required"> <div class="form-single-column" role="group" aria-labelledby="label_90" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_90" type="radio" class="form-radio validate[required]" id="input_90_0" name="q90_doYou90" required="" value="Yes" /><label id="label_input_90_0" for="input_90_0">Yes</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input aria-describedby="label_90" type="radio" class="form-radio validate[required]" id="input_90_1" name="q90_doYou90" required="" value="No" /><label id="label_input_90_1" for="input_90_1">No</label></span></div> </div> </li> <li class="form-line" data-type="control_divider" id="id_69"> <div id="cid_69" class="form-input-wide"> <div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px"></div> </div> </li> <li class="form-line" data-type="control_text" id="id_37"> <div id="cid_37" class="form-input-wide"> <div id="text_37" class="form-html" data-component="text" tabindex="0"> <p style="text-align: center;"><strong><span style="color: #000000; font-size: 18pt;">Private Program Information</span></strong></p> <p><span style="color: #000000;">Please list the most appropriate staff member(s) our team should contact for questions</span> <span style="color: #000000;">about the information submitted on this form. <em>This information will not be publicly shared</em></span><em> <span style="color: #000000;">by our staff.</span></em></p> <p>聽</p> </div> </div> </li> <li class="form-line jf-required" data-type="control_textbox" id="id_71"><label class="form-label form-label-left form-label-auto" id="label_71" for="input_71" aria-hidden="false"> Primary Contact First Name<span class="form-required">*</span> </label> <div id="cid_71" class="form-input jf-required"> <input type="text" id="input_71" name="q71_primaryContact" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_71" required="" value="" /> </div> </li> <li class="form-line jf-required" data-type="control_textbox" id="id_72"><label class="form-label form-label-left form-label-auto" id="label_72" for="input_72" aria-hidden="false"> Primary Contact Last Name<span class="form-required">*</span> </label> <div id="cid_72" class="form-input jf-required"> <input type="text" id="input_72" name="q72_primaryContact72" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_72" required="" value="" /> </div> </li> <li class="form-line jf-required" data-type="control_phone" id="id_74"><label class="form-label form-label-left form-label-auto" id="label_74" for="input_74_area" aria-hidden="false"> Primary Contact Phone <span class="form-required">*</span> </label> <div id="cid_74" class="form-input jf-required"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode"><input type="tel" id="input_74_area" name="q74_primaryContact74[area]" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" data-component="areaCode" aria-labelledby="label_74 sublabel_74_area" required="" value="" /><span class="phone-separate" aria-hidden="true">聽-</span><label class="form-sub-label" for="input_74_area" id="sublabel_74_area" style="min-height:13px">Area Code</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone"><input type="tel" id="input_74_phone" name="q74_primaryContact74[phone]" class="form-textbox validate[required]" data-defaultvalue="" autoComplete="nope" data-component="phone" aria-labelledby="label_74 sublabel_74_phone" required="" value="" /><label class="form-sub-label" for="input_74_phone" id="sublabel_74_phone" style="min-height:13px">Phone Number</label></span></div> </div> </li> <li class="form-line jf-required" data-type="control_email" id="id_75"><label class="form-label form-label-left form-label-auto" id="label_75" for="input_75" aria-hidden="false"> Primary Contact Email<span class="form-required">*</span> </label> <div id="cid_75" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_75" name="q75_primaryContact75" class="form-textbox validate[required, Email]" data-defaultvalue="" autoComplete="nope" size="30" data-component="email" aria-labelledby="label_75 sublabel_input_75" required="" value="" /><label class="form-sub-label" for="input_75" id="sublabel_input_75" style="min-height:13px">example@example.com</label></span> </div> </li> <li class="form-line" data-type="control_textbox" id="id_76"><label class="form-label form-label-left form-label-auto" id="label_76" for="input_76" aria-hidden="false"> Secondary Contact First Name </label> <div id="cid_76" class="form-input"> <input type="text" id="input_76" name="q76_secondaryContact" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_76" value="" /> </div> </li> <li class="form-line" data-type="control_textbox" id="id_77"><label class="form-label form-label-left form-label-auto" id="label_77" for="input_77" aria-hidden="false"> Secondary Contact Last Name </label> <div id="cid_77" class="form-input"> <input type="text" id="input_77" name="q77_secondaryContact77" data-type="input-textbox" class="form-textbox" data-defaultvalue="" autoComplete="nope" size="20" data-component="textbox" aria-labelledby="label_77" value="" /> </div> </li> <li class="form-line" data-type="control_phone" id="id_78"><label class="form-label form-label-left form-label-auto" id="label_78" for="input_78_area" aria-hidden="false"> Secondary Contact Phone </label> <div id="cid_78" class="form-input"> <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode"><input type="tel" id="input_78_area" name="q78_secondaryContact78[area]" class="form-textbox" data-defaultvalue="" autoComplete="nope" data-component="areaCode" aria-labelledby="label_78 sublabel_78_area" value="" /><span class="phone-separate" aria-hidden="true">聽-</span><label class="form-sub-label" for="input_78_area" id="sublabel_78_area" style="min-height:13px">Area Code</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone"><input type="tel" id="input_78_phone" name="q78_secondaryContact78[phone]" class="form-textbox" data-defaultvalue="" autoComplete="nope" data-component="phone" aria-labelledby="label_78 sublabel_78_phone" value="" /><label class="form-sub-label" for="input_78_phone" id="sublabel_78_phone" style="min-height:13px">Phone Number</label></span></div> </div> </li> <li class="form-line" data-type="control_email" id="id_79"><label class="form-label form-label-left form-label-auto" id="label_79" for="input_79" aria-hidden="false"> Secondary Contact Email </label> <div id="cid_79" class="form-input"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_79" name="q79_secondaryContact79" class="form-textbox validate[Email]" data-defaultvalue="" autoComplete="nope" size="30" data-component="email" aria-labelledby="label_79 sublabel_input_79" value="" /><label class="form-sub-label" for="input_79" id="sublabel_input_79" style="min-height:13px">example@example.com</label></span> </div> </li> <li class="form-line" data-type="control_text" id="id_70"> <div id="cid_70" class="form-input-wide"> <div id="text_70" class="form-html" data-component="text" tabindex="0"> <p>Due to issues with staff turnover, name changes, etc., it is requested that you provide a聽non-named email address in the event that other emails to your organization bounce聽and the VictimConnect Resource Center needs to contact your organization. For example, several members of our team check <a href="mailto:hotlineleadership@victimsofcrime.org" target="_blank" rel="nofollow">hotlineleadership@victimsofcrime.org</a>.</p> </div> </div> </li> <li class="form-line jf-required" data-type="control_email" id="id_80"><label class="form-label form-label-left form-label-auto" id="label_80" for="input_80" aria-hidden="false"> Backup Organization Contact Email<span class="form-required">*</span> </label> <div id="cid_80" class="form-input jf-required"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_80" name="q80_backupOrganization" class="form-textbox validate[required, Email]" data-defaultvalue="" autoComplete="nope" size="30" data-component="email" aria-labelledby="label_80 sublabel_input_80" required="" value="" /><label class="form-sub-label" for="input_80" id="sublabel_input_80" style="min-height:13px">example@example.com</label></span> </div> </li> <li class="form-line" data-type="control_text" id="id_38"> <div id="cid_38" class="form-input-wide"> <div id="text_38" class="form-html" data-component="text" tabindex="0"> <p><strong><span style="color: #000000;">Private Address</span></strong></p> <p><span style="color: #000000;">This information will not be shared publicly.</span></p> <p>聽</p> </div> </div> </li> <li class="form-line" data-type="control_address" id="id_81"><label class="form-label form-label-left form-label-auto" id="label_81" for="input_81_addr_line1" aria-hidden="false"> Address </label> <div id="cid_81" class="form-input"> <div summary="" class="form-address-table jsTest-addressField"> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_81_addr_line1" name="q81_address81[addr_line1]" class="form-textbox form-address-line" data-defaultvalue="" autoComplete="nope" data-component="address_line_1" aria-labelledby="label_81 sublabel_81_addr_line1" value="" /><label class="form-sub-label" for="input_81_addr_line1" id="sublabel_81_addr_line1" style="min-height:13px">Street Address</label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_81_addr_line2" name="q81_address81[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autoComplete="nope" data-component="address_line_2" aria-labelledby="label_81 sublabel_81_addr_line2" value="" /><label class="form-sub-label" for="input_81_addr_line2" id="sublabel_81_addr_line2" style="min-height:13px">Street Address Line 2</label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_81_city" name="q81_address81[city]" class="form-textbox form-address-city" data-defaultvalue="" autoComplete="nope" data-component="city" aria-labelledby="label_81 sublabel_81_city" value="" /><label class="form-sub-label" for="input_81_city" id="sublabel_81_city" style="min-height:13px">City</label></span></span><span class="form-address-line form-address-state-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_81_state" name="q81_address81[state]" class="form-textbox form-address-state" data-defaultvalue="" autoComplete="nope" data-component="state" aria-labelledby="label_81 sublabel_81_state" value="" /><label class="form-sub-label" for="input_81_state" id="sublabel_81_state" style="min-height:13px">State / Province</label></span></span></div> <div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_81_postal" name="q81_address81[postal]" class="form-textbox form-address-postal" data-defaultvalue="" autoComplete="nope" data-component="zip" aria-labelledby="label_81 sublabel_81_postal" value="" /><label class="form-sub-label" for="input_81_postal" id="sublabel_81_postal" style="min-height:13px">Postal / Zip Code</label></span></span></div> </div> </div> </li> <li class="form-line" data-type="control_text" id="id_40"> <div id="cid_40" class="form-input-wide"> <div id="text_40" class="form-html" data-component="text" tabindex="0"> <p><strong>Additional Information</strong></p> <p>Please use this space to add any additional information the organization would like our聽staff to know. This could include any of the following information:聽</p> <ul> <li>The best way to make referrals or important intake information or criteria</li> <li>Relevant hotline details</li> <li>If you serve multiple counties, and/or states, name those service areas</li> <li><span style="color: #000000;">Information about gender, age, or population restrictions</span></li> <li><span style="color: #000000;">Services provided to special populations or specific disability accommodations</span></li> <li><span style="color: #000000;">Additional information about any services provided</span></li> </ul> </div> </div> </li> <li class="form-line" data-type="control_textarea" id="id_82"><label class="form-label form-label-left form-label-auto" id="label_82" for="input_82" aria-hidden="true"> </label> <div id="cid_82" class="form-input"> <span class="form-sub-label-container" style="vertical-align:top"><textarea id="input_82" class="form-textarea" name="q82_input82" cols="40" rows="6" data-component="textarea" aria-labelledby="label_82 sublabel_input_82"></textarea><label class="form-sub-label" for="input_82" id="sublabel_input_82" style="min-height:13px">Please indicate whether or not you want the information you provide here made public聽through our hotline services.</label></span> </div> </li> <li class="form-line" data-type="control_button" id="id_41"> <div id="cid_41" class="form-input-wide"> <div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField"><button id="input_41" type="submit" class="form-submit-button submit-button jf-form-buttons jsTest-submitField legacy-submit" data-component="button" data-content="">Submit</button></div> </div> </li> <li style="display:none">Should be Empty: <input type="text" name="website" value="" type="hidden" /></li> </ul> </div> <script> JotForm.showJotFormPowered = "0"; </script> <script> JotForm.poweredByText = "Powered by Jotform"; </script> <script> JotForm.hipaa = true; </script> <script> JotForm.showHIPAABadge = true; </script><input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="211883668810059" /> <script type="text/javascript"> var all_spc = document.querySelectorAll("form[id='211883668810059'] .si" + "mple" + "_spc"); for (var i = 0; i < all_spc.length; i++) { all_spc[i].value = "211883668810059-211883668810059"; } </script> </form></body> </html><script type="text/javascript">JotForm.isNewSACL=true;</script>