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.id_488ca356-cc1f-44f0-8d55-5b7922ffe4a5 .sli-input:-moz-placeholder { color: #CCCCCC; opacity: 1; }</style> <div hidden="true" layout-style-id="sli-forms-styles_v02"></div> <div class="sli-loading-message" id="id_null"> <div class="sli-loading-spinner"></div> <div> <p>Loading....</p> </div> </div> <div class="sli-content-pane sli-widget" content-pane="0" id="id_8e3bccfa-85d9-47d4-a6c8-951bb5f90638_contentView" data-token-id="488ca356-cc1f-44f0-8d55-5b7922ffe4a5" data-ignite-view="contentView" data-internal-id="8e3bccfa-85d9-47d4-a6c8-951bb5f90638" style="display:none"> <div class="sli-row" id="id_c67a9f47-7f05-432b-b297-c196c8f4f943"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_374981fa-2022-46ff-8e7e-01d7ff0de9c3"> <div class="sli-element sli-image" id="id_9b1ed10e-0f34-4d3f-b8a6-6dea7957ab23"> <img entity-id="a3239a3e-9cae-4e61-9888-f7ff2bfac35f" id="id_9b1ed10e-0f34-4d3f-b8a6-6dea7957ab23_img" align="center" alt="" src="https://healthhiv.salsalabs.org/public/images/image-placeholder.png" ignite-image-src="https://healthhiv.salsalabs.org/97ad0874-7db4-4996-bdda-59fecd1e8f48/a3239a3e-9cae-4e61-9888-f7ff2bfac35f.png" /> </div> </div> </div> <div class="sli-row" id="id_a47ce064-56fe-4277-86fd-9eb0d3703c5a"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_269ae11b-2042-4ff6-9e6d-947615fa2a92"> <div class="sli-callout sli-element" id="id_d610e951-7369-4b0b-adab-d11e92015281"> <h3 style="text-align:center"> Join the National Coalition for LGBTQ Health to<br /> advance LGBTQ health equity.  </h3> </div> </div> </div> <div class="sli-row" id="id_e68241e5-27b5-44ff-807b-9a7075a5d8e1"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_1f5f7b3c-d9b9-4f5d-ac6b-ebae06da2ba6"> <div class="sli-row" id="id_c54334cb-c123-492a-af0a-748e6c9eb0f2"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end" data-ignite-container-type="formContainer" id="id_e3fbca61-320f-4647-8842-fd93184037b2_container"> <div class="sli-element sli-form-wrapper" id="id_e3fbca61-320f-4647-8842-fd93184037b2" ignite-bind-only="ignite-bind-only" ignite-activity-id="b5a4a272-485e-423c-a1ae-5f22b3d93432" ignite-activity-type="Subscribe"> <form class="sli-form fv-form fv-form-salsa" data-fv-framework="salsa" novalidate="novalidate" data-ignite-form-id="b5a4a272-485e-423c-a1ae-5f22b3d93432" id="id_e3fbca61-320f-4647-8842-fd93184037b2_form"> <div class="sli-row" id="id_926b067a-8023-4bf3-9784-8c318eb91a8f"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="elementStep" id="id_4f37e5be-277c-4773-ac3d-5cc08acdedf4" data-ignite-step-id="1"> <div class="sli-row" id="id_ac48f1bd-c654-4d03-816d-05bbbce5ba61"> <div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_8599a1e5-b945-47a5-bce2-1889c8380cf7"> <div class="sli-field-person-firstname sli-form-field sli-element" data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" id="id_01941dd0-f19c-4fda-a03d-6f5abd80801e"> <label class="sli-required-true sli-label" for="id_01941dd0-f19c-4fda-a03d-6f5abd80801e_input" id="id_01941dd0-f19c-4fda-a03d-6f5abd80801e_label">First Name*</label> <input class="sli-input sli-input-person-firstname" type="text" data-ignite-field-id="5d5a2165-f19e-4371-851b-183a6b92402b" name="field-person-firstname" maxlength="36" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 36 characters." id="id_01941dd0-f19c-4fda-a03d-6f5abd80801e_input" salsa-reference-name="person-firstname" /> </div> </div> <div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_a604301f-62e4-4f89-94a5-0d5a807720da"> <div class="sli-field-person-lastname sli-form-field sli-element" data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" id="id_5a0ccbb5-ae46-4f63-a5c4-be1d83e1dcc4"> <label class="sli-required-true sli-label" for="id_5a0ccbb5-ae46-4f63-a5c4-be1d83e1dcc4_input" id="id_5a0ccbb5-ae46-4f63-a5c4-be1d83e1dcc4_label">Last Name*</label> <input class="sli-input sli-input-person-lastname" type="text" data-ignite-field-id="8d21a878-287a-491f-a362-b8ee2aa71819" name="field-person-lastname" maxlength="100" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 100 characters." id="id_5a0ccbb5-ae46-4f63-a5c4-be1d83e1dcc4_input" salsa-reference-name="person-lastname" /> </div> </div> </div> <div class="sli-row" id="id_ce3c0d52-a7b4-4b8a-9347-91b5bc84e185"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_35973e70-55bb-4a9c-84e1-67b75003c7a2"> <div class="sli-field-cff7ba51-3816-4223-9316-e14a6d267aa8 sli-form-field sli-element" data-ignite-field-id="cff7ba51-3816-4223-9316-e14a6d267aa8" id="id_c0460b26-939e-4556-9219-e7a1cef88d6a"> <label class="sli-required-false sli-label" for="id_c0460b26-939e-4556-9219-e7a1cef88d6a_input" id="id_c0460b26-939e-4556-9219-e7a1cef88d6a_label">Position/Title</label> <input class="sli-input sli-input-cff7ba51-3816-4223-9316-e14a6d267aa8" type="text" data-ignite-field-id="cff7ba51-3816-4223-9316-e14a6d267aa8" name="field-cff7ba51-3816-4223-9316-e14a6d267aa8" placeholder="" maxlength="150" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 150 characters." id="id_c0460b26-939e-4556-9219-e7a1cef88d6a_input" salsa-reference-name="scf_position_title" /> </div> <div class="sli-field-3e827b8f-2517-4a7e-88a0-be2ad76f3e6c sli-form-field sli-element" data-ignite-field-id="3e827b8f-2517-4a7e-88a0-be2ad76f3e6c" id="id_2d27a3cb-eb5d-4aed-ba6c-ff0a809dfd24"> <label class="sli-required-true sli-label" for="id_2d27a3cb-eb5d-4aed-ba6c-ff0a809dfd24_input" id="id_2d27a3cb-eb5d-4aed-ba6c-ff0a809dfd24_label">Organization*</label> <input class="sli-input sli-input-3e827b8f-2517-4a7e-88a0-be2ad76f3e6c" type="text" data-ignite-field-id="3e827b8f-2517-4a7e-88a0-be2ad76f3e6c" name="field-3e827b8f-2517-4a7e-88a0-be2ad76f3e6c" placeholder="" maxlength="200" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 200 characters." id="id_2d27a3cb-eb5d-4aed-ba6c-ff0a809dfd24_input" salsa-reference-name="scf_organization" /> </div> <div class="sli-field-address-line1 sli-form-field sli-element" data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" id="id_9aeeb162-9f62-45f5-bcb3-cc8a2627a255"> <label class="sli-required-true sli-label" for="id_9aeeb162-9f62-45f5-bcb3-cc8a2627a255_input" id="id_9aeeb162-9f62-45f5-bcb3-cc8a2627a255_label">Address, line 1*</label> <input class="sli-input sli-input-address-line1" type="text" data-ignite-field-id="f775c79a-df41-43fb-96de-ee2360254689" name="field-address-line1" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 128 characters." id="id_9aeeb162-9f62-45f5-bcb3-cc8a2627a255_input" salsa-reference-name="address-line1" /> </div> <div class="sli-field-person-work_phone sli-form-field sli-element" data-ignite-field-id="ebee4777-169c-4ec8-9c38-de27e05cc235" id="id_a15a684e-89bd-40aa-81d5-cdad22331f62"> <label class="sli-required-true sli-label" for="id_a15a684e-89bd-40aa-81d5-cdad22331f62_input" id="id_a15a684e-89bd-40aa-81d5-cdad22331f62_label">Work Phone*</label> <input class="sli-input sli-input-person-work_phone" type="text" data-ignite-field-id="ebee4777-169c-4ec8-9c38-de27e05cc235" name="field-person-work_phone" placeholder="555-555-5555" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 128 characters." id="id_a15a684e-89bd-40aa-81d5-cdad22331f62_input" salsa-reference-name="person-work_phone" /> </div> </div> </div> <div class="sli-row" id="id_d4bcb248-6f77-4a07-9a8a-8d972e3ea2fa"> <div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_6104d2ca-0d31-4cc3-8bb9-c90533860cf9"> <div class="sli-field-address-city sli-form-field sli-element" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2" id="id_caebd7a1-c0ef-499d-bfa8-75704a75d2d0"> <label class="sli-required-true sli-label" for="id_caebd7a1-c0ef-499d-bfa8-75704a75d2d0_input" id="id_caebd7a1-c0ef-499d-bfa8-75704a75d2d0_label">City*</label> <input class="sli-input sli-input-address-city" type="text" data-ignite-field-id="a102d60f-f8ab-47eb-8ee0-864cfa1fc5b2" name="field-address-city" maxlength="64" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 64 characters." id="id_caebd7a1-c0ef-499d-bfa8-75704a75d2d0_input" salsa-reference-name="address-city" /> </div> </div> <div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_b6c3dca3-5c31-4b39-9659-69a8c18d7535"> <div class="sli-field-address-state sli-form-field sli-element" data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" id="id_951f135b-a302-46ff-85f6-abe0b2eb5288"> <label class="sli-required-true sli-label" for="id_951f135b-a302-46ff-85f6-abe0b2eb5288_input" id="id_951f135b-a302-46ff-85f6-abe0b2eb5288_label">State*</label> <select class="sli-select-address-state sli-input" name="field-address-state" data-ignite-field-id="3f8b9098-ff2d-4384-bb95-425f113028c0" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" id="id_951f135b-a302-46ff-85f6-abe0b2eb5288_input" salsa-reference-name="address-state"><option value="" selected="selected"> Choose one...</option><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AS">American Samoa</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="AA">Armed Forces America</option><option value="AE">Armed Forces Europe</option><option value="AP">Armed Forces Pacific</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="GU">Guam</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="MP">Northern Mariana Islands</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PA">Pennsylvania</option><option value="PR">Puerto Rico</option><option value="RI">Rhode Island</option><option value="SC">South Carolina</option><option value="SD">South Dakota</option><option value="TN">Tennessee</option><option value="TX">Texas</option><option value="UM">United States Minor Outlying Islands</option><option value="UT">Utah</option><option value="VT">Vermont</option><option value="VI">Virgin Islands</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option></select> </div> </div> <div class="sli-large-4 sli-medium-4 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_cdc3327d-7e35-414c-8344-b95d7e4c7c2e"> <div class="sli-field-address-zip sli-form-field sli-element" data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" id="id_510c5cd9-d0fa-43de-95c4-d8ac92f6183d"> <label class="sli-required-true sli-label" for="id_510c5cd9-d0fa-43de-95c4-d8ac92f6183d_input" id="id_510c5cd9-d0fa-43de-95c4-d8ac92f6183d_label">Zip Code*</label> <input class="sli-input sli-input-address-zip" type="text" data-ignite-field-id="44e5ad15-1fdd-4ba8-bf38-f5cbaad023c2" name="field-address-zip" maxlength="20" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 20 characters." data-fv-zipcode="true" data-fv-zipcode-priority="1" data-fv-zipcode-country="US" data-fv-zipcode-message="This value is not valid as a %s postal code" data-fv-regexp="true" data-fv-regexp-priority="2" data-fv-regexp-regexp="^(\d{5}|\d{5}-\d{4})?$" data-fv-regexp-message="Zip Code must be formatted as: "55555" or "55555-5555"" id="id_510c5cd9-d0fa-43de-95c4-d8ac92f6183d_input" salsa-reference-name="address-zip" /> </div> </div> </div> <div class="sli-row" id="id_aee8ff2c-43d5-4904-b7ff-625d602a9f87"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_3eceeb75-9de5-417d-927a-562a59f349c2"> <div class="sli-field-contact-email sli-form-field sli-element" data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" id="id_a5faf312-9a8e-4738-ab3d-0fcd0c02e246"> <label class="sli-required-true sli-label" for="id_a5faf312-9a8e-4738-ab3d-0fcd0c02e246_input" id="id_a5faf312-9a8e-4738-ab3d-0fcd0c02e246_label">Email Address*</label> <input class="sli-input sli-input-contact-email" type="email" data-ignite-field-id="2851b463-606f-40c8-bb3d-d31f399e6896" name="field-contact-email" maxlength="128" required="required" data-fv-notempty="true" data-fv-notempty-message="This field requires a value" data-fv-stringlength="true" data-fv-stringlengthmessage="Please limit your input to at most 128 characters." data-fv-regexp="true" data-fv-regexp-regexp="^[^@\s]+@([^@\s]+\.)+[^@\s]+$" data-fv-regexp-message="Please enter a valid email address" id="id_a5faf312-9a8e-4738-ab3d-0fcd0c02e246_input" salsa-reference-name="contact-email" /> </div> </div> </div> <div class="sli-row" id="id_66def66c-2875-4702-a40d-2a75a415ae28"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_6bf239b0-a628-4cda-8142-f95032a70d58"> <div class="sli-element sli-text" id="id_d77864fa-0abe-4080-a129-593ae73376e6"> <div id="id_d77864fa-0abe-4080-a129-593ae73376e6_inner"> <p> <strong>Which of the following LGBT health issues do you or your organization primarily work to address?</strong> </p> </div> </div> </div> </div> <div class="sli-row" id="id_d063ce71-0bba-4578-8463-433b3872f5d0"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_615da398-b40d-4741-8af9-4bb0bf5fba3f"> <div class="sli-row" id="id_c826c6bf-6288-483c-b45e-9857ef136972"> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_59a09945-40f5-4046-80e1-343ef5b9b78a"> <div class="sli-field-e0e683bc-0373-465b-8d87-d70de7a9ad7e sli-form-field sli-element" data-ignite-field-id="e0e683bc-0373-465b-8d87-d70de7a9ad7e" id="id_4abaf94c-315f-4704-a87d-a6930612304c"> <label class="sli-required-false sli-label" for="id_4abaf94c-315f-4704-a87d-a6930612304c_input" id="id_4abaf94c-315f-4704-a87d-a6930612304c_label">Clinical / Medical Provider</label> <div class="sli-select-radio sli-orientation-vertical" id="id_4abaf94c-315f-4704-a87d-a6930612304c_input" salsa-reference-name="scf_clinical_medical_provider"> <label class="sli-label" for="id_4abaf94c-315f-4704-a87d-a6930612304c_Yes"><input data-ignite-field-id="e0e683bc-0373-465b-8d87-d70de7a9ad7e" id="id_4abaf94c-315f-4704-a87d-a6930612304c_Yes" type="radio" name="field-e0e683bc-0373-465b-8d87-d70de7a9ad7e" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_4abaf94c-315f-4704-a87d-a6930612304c_No"><input data-ignite-field-id="e0e683bc-0373-465b-8d87-d70de7a9ad7e" id="id_4abaf94c-315f-4704-a87d-a6930612304c_No" type="radio" name="field-e0e683bc-0373-465b-8d87-d70de7a9ad7e" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_18a608fe-42ff-4083-b443-73bfdbf27301"> <div class="sli-field-e50ff4bb-cdda-47d6-a6b3-0239ce0118bf sli-form-field sli-element" data-ignite-field-id="e50ff4bb-cdda-47d6-a6b3-0239ce0118bf" id="id_f445a109-9e7a-4a46-8953-1a4b383cddea"> <label class="sli-required-false sli-label" for="id_f445a109-9e7a-4a46-8953-1a4b383cddea_input" id="id_f445a109-9e7a-4a46-8953-1a4b383cddea_label">Behavioral Health</label> <div class="sli-select-radio sli-orientation-vertical" id="id_f445a109-9e7a-4a46-8953-1a4b383cddea_input" salsa-reference-name="scf_behavioral_health"> <label class="sli-label" for="id_f445a109-9e7a-4a46-8953-1a4b383cddea_Yes"><input data-ignite-field-id="e50ff4bb-cdda-47d6-a6b3-0239ce0118bf" id="id_f445a109-9e7a-4a46-8953-1a4b383cddea_Yes" type="radio" name="field-e50ff4bb-cdda-47d6-a6b3-0239ce0118bf" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_f445a109-9e7a-4a46-8953-1a4b383cddea_No"><input data-ignite-field-id="e50ff4bb-cdda-47d6-a6b3-0239ce0118bf" id="id_f445a109-9e7a-4a46-8953-1a4b383cddea_No" type="radio" name="field-e50ff4bb-cdda-47d6-a6b3-0239ce0118bf" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_b281d7c8-72d1-4f47-a19e-56121c25e86a"> <div class="sli-field-f0990ddd-c571-4453-84a8-c6bb59b2af79 sli-form-field sli-element" data-ignite-field-id="f0990ddd-c571-4453-84a8-c6bb59b2af79" id="id_6564dd63-1057-4d56-8499-49a2addb9470"> <label class="sli-required-false sli-label" for="id_6564dd63-1057-4d56-8499-49a2addb9470_input" id="id_6564dd63-1057-4d56-8499-49a2addb9470_label">Gender Identity</label> <div class="sli-select-radio sli-orientation-vertical" id="id_6564dd63-1057-4d56-8499-49a2addb9470_input" salsa-reference-name="scf_gender_identity"> <label class="sli-label" for="id_6564dd63-1057-4d56-8499-49a2addb9470_Yes"><input data-ignite-field-id="f0990ddd-c571-4453-84a8-c6bb59b2af79" id="id_6564dd63-1057-4d56-8499-49a2addb9470_Yes" type="radio" name="field-f0990ddd-c571-4453-84a8-c6bb59b2af79" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_6564dd63-1057-4d56-8499-49a2addb9470_No"><input data-ignite-field-id="f0990ddd-c571-4453-84a8-c6bb59b2af79" id="id_6564dd63-1057-4d56-8499-49a2addb9470_No" type="radio" name="field-f0990ddd-c571-4453-84a8-c6bb59b2af79" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_225fd028-f7f1-4ff5-8b59-b1f43ec3d1cb"> <div class="sli-field-9e66e5e3-1f37-42f6-b2c7-14c18f9708c4 sli-form-field sli-element" data-ignite-field-id="9e66e5e3-1f37-42f6-b2c7-14c18f9708c4" id="id_b68eaea1-658e-47f6-8681-418c7b280772"> <label class="sli-required-false sli-label" for="id_b68eaea1-658e-47f6-8681-418c7b280772_input" id="id_b68eaea1-658e-47f6-8681-418c7b280772_label">Physical Health/Fitness</label> <div class="sli-select-radio sli-orientation-vertical" id="id_b68eaea1-658e-47f6-8681-418c7b280772_input" salsa-reference-name="scf_physical_health_fitness"> <label class="sli-label" for="id_b68eaea1-658e-47f6-8681-418c7b280772_Yes"><input data-ignite-field-id="9e66e5e3-1f37-42f6-b2c7-14c18f9708c4" id="id_b68eaea1-658e-47f6-8681-418c7b280772_Yes" type="radio" name="field-9e66e5e3-1f37-42f6-b2c7-14c18f9708c4" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_b68eaea1-658e-47f6-8681-418c7b280772_No"><input data-ignite-field-id="9e66e5e3-1f37-42f6-b2c7-14c18f9708c4" id="id_b68eaea1-658e-47f6-8681-418c7b280772_No" type="radio" name="field-9e66e5e3-1f37-42f6-b2c7-14c18f9708c4" value="false" /> No</label> </div> </div> </div> </div> <div class="sli-row" id="id_95a7cee3-5dc6-4cb7-a592-ac4fda95d918"> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_f2ea6fc1-89bd-4812-b817-04347f41295c"> <div class="sli-field-0fabe886-e569-4f37-88e0-55e88c8492a9 sli-form-field sli-element" data-ignite-field-id="0fabe886-e569-4f37-88e0-55e88c8492a9" id="id_147e5517-5138-4a73-b508-23c3cba85ec9"> <label class="sli-required-false sli-label" for="id_147e5517-5138-4a73-b508-23c3cba85ec9_input" id="id_147e5517-5138-4a73-b508-23c3cba85ec9_label">Sexually Transmitted Infections (STIs)</label> <div class="sli-select-radio sli-orientation-vertical" id="id_147e5517-5138-4a73-b508-23c3cba85ec9_input" salsa-reference-name="scf_sexually_transmitted_infections_stis_"> <label class="sli-label" for="id_147e5517-5138-4a73-b508-23c3cba85ec9_Yes"><input data-ignite-field-id="0fabe886-e569-4f37-88e0-55e88c8492a9" id="id_147e5517-5138-4a73-b508-23c3cba85ec9_Yes" type="radio" name="field-0fabe886-e569-4f37-88e0-55e88c8492a9" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_147e5517-5138-4a73-b508-23c3cba85ec9_No"><input data-ignite-field-id="0fabe886-e569-4f37-88e0-55e88c8492a9" id="id_147e5517-5138-4a73-b508-23c3cba85ec9_No" type="radio" name="field-0fabe886-e569-4f37-88e0-55e88c8492a9" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_66642745-7b46-4374-8b7f-7eeace4ba9f7"> <div class="sli-field-a219d50d-b9a8-47f9-a3fb-178d2ff6573f sli-form-field sli-element" data-ignite-field-id="a219d50d-b9a8-47f9-a3fb-178d2ff6573f" id="id_a8608c22-8b94-4305-b19d-53c5b4c64955"> <label class="sli-required-false sli-label" for="id_a8608c22-8b94-4305-b19d-53c5b4c64955_input" id="id_a8608c22-8b94-4305-b19d-53c5b4c64955_label">Stigma/Discrimination</label> <div class="sli-select-radio sli-orientation-vertical" id="id_a8608c22-8b94-4305-b19d-53c5b4c64955_input" salsa-reference-name="scf_stigma_discrimination"> <label class="sli-label" for="id_a8608c22-8b94-4305-b19d-53c5b4c64955_Yes"><input data-ignite-field-id="a219d50d-b9a8-47f9-a3fb-178d2ff6573f" id="id_a8608c22-8b94-4305-b19d-53c5b4c64955_Yes" type="radio" name="field-a219d50d-b9a8-47f9-a3fb-178d2ff6573f" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_a8608c22-8b94-4305-b19d-53c5b4c64955_No"><input data-ignite-field-id="a219d50d-b9a8-47f9-a3fb-178d2ff6573f" id="id_a8608c22-8b94-4305-b19d-53c5b4c64955_No" type="radio" name="field-a219d50d-b9a8-47f9-a3fb-178d2ff6573f" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_3f0e0774-6307-4a24-b92f-f8a6d6615ab4"> <div class="sli-field-31985fc2-7396-4b5f-84bb-5fe2ea3f9a68 sli-form-field sli-element" data-ignite-field-id="31985fc2-7396-4b5f-84bb-5fe2ea3f9a68" id="id_4388db40-8cb4-47cd-880c-92cb49cf3bff"> <label class="sli-required-false sli-label" for="id_4388db40-8cb4-47cd-880c-92cb49cf3bff_input" id="id_4388db40-8cb4-47cd-880c-92cb49cf3bff_label">Violence</label> <div class="sli-select-radio sli-orientation-vertical" id="id_4388db40-8cb4-47cd-880c-92cb49cf3bff_input" salsa-reference-name="scf_violence"> <label class="sli-label" for="id_4388db40-8cb4-47cd-880c-92cb49cf3bff_Yes"><input data-ignite-field-id="31985fc2-7396-4b5f-84bb-5fe2ea3f9a68" id="id_4388db40-8cb4-47cd-880c-92cb49cf3bff_Yes" type="radio" name="field-31985fc2-7396-4b5f-84bb-5fe2ea3f9a68" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_4388db40-8cb4-47cd-880c-92cb49cf3bff_No"><input data-ignite-field-id="31985fc2-7396-4b5f-84bb-5fe2ea3f9a68" id="id_4388db40-8cb4-47cd-880c-92cb49cf3bff_No" type="radio" name="field-31985fc2-7396-4b5f-84bb-5fe2ea3f9a68" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_02b5c851-bc0e-4057-9694-0a05da95ea8e"> <div class="sli-field-20ff73b2-7042-4f08-973c-e8b39f15ca69 sli-form-field sli-element" data-ignite-field-id="20ff73b2-7042-4f08-973c-e8b39f15ca69" id="id_2e5c49f7-3295-4615-a9ef-c5e70dab6ef7"> <label class="sli-required-false sli-label" for="id_2e5c49f7-3295-4615-a9ef-c5e70dab6ef7_input" id="id_2e5c49f7-3295-4615-a9ef-c5e70dab6ef7_label">Health Insurance/Care Access</label> <div class="sli-select-radio sli-orientation-vertical" id="id_2e5c49f7-3295-4615-a9ef-c5e70dab6ef7_input" salsa-reference-name="scf_discrimination_accessing_health_insurance_health_care"> <label class="sli-label" for="id_2e5c49f7-3295-4615-a9ef-c5e70dab6ef7_Yes"><input data-ignite-field-id="20ff73b2-7042-4f08-973c-e8b39f15ca69" id="id_2e5c49f7-3295-4615-a9ef-c5e70dab6ef7_Yes" type="radio" name="field-20ff73b2-7042-4f08-973c-e8b39f15ca69" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_2e5c49f7-3295-4615-a9ef-c5e70dab6ef7_No"><input data-ignite-field-id="20ff73b2-7042-4f08-973c-e8b39f15ca69" id="id_2e5c49f7-3295-4615-a9ef-c5e70dab6ef7_No" type="radio" name="field-20ff73b2-7042-4f08-973c-e8b39f15ca69" value="false" /> No</label> </div> </div> </div> </div> </div> </div> <div class="sli-row" id="id_f0f52c81-36dc-4037-8ae8-bf98aae9a21c"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_a52342f6-aa0c-4a9c-b216-9cdfa27abae4"> <div class="sli-element sli-text" id="id_1fb9a323-02be-4e5e-a266-0413c1728c62"> <div id="id_1fb9a323-02be-4e5e-a266-0413c1728c62_inner"> <p> <strong>Which of the following populations do you primarily work with or for to address issues related to LGBT health?</strong> </p> </div> </div> </div> </div> <div class="sli-row" id="id_df781473-9383-4ae9-ae36-5ab9de009e5b"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_52138f97-f680-4d12-ad1a-7165f0a38abc"> <div class="sli-row" id="id_4473d9ed-2166-40b7-9ba0-dc35fe8b1ee0"> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_d7e8a95b-b823-425f-8c32-ec31c175193d"> <div class="sli-field-fc93ab67-83fa-4730-b43e-2dc087401ce2 sli-form-field sli-element" data-ignite-field-id="fc93ab67-83fa-4730-b43e-2dc087401ce2" id="id_11517f54-6ecb-493d-b61f-004afbd7a86b"> <label class="sli-required-false sli-label" for="id_11517f54-6ecb-493d-b61f-004afbd7a86b_input" id="id_11517f54-6ecb-493d-b61f-004afbd7a86b_label">Youth (under age 25)</label> <div class="sli-select-radio sli-orientation-vertical" id="id_11517f54-6ecb-493d-b61f-004afbd7a86b_input" salsa-reference-name="scf_youth_under_age_25_"> <label class="sli-label" for="id_11517f54-6ecb-493d-b61f-004afbd7a86b_Yes"><input data-ignite-field-id="fc93ab67-83fa-4730-b43e-2dc087401ce2" id="id_11517f54-6ecb-493d-b61f-004afbd7a86b_Yes" type="radio" name="field-fc93ab67-83fa-4730-b43e-2dc087401ce2" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_11517f54-6ecb-493d-b61f-004afbd7a86b_No"><input data-ignite-field-id="fc93ab67-83fa-4730-b43e-2dc087401ce2" id="id_11517f54-6ecb-493d-b61f-004afbd7a86b_No" type="radio" name="field-fc93ab67-83fa-4730-b43e-2dc087401ce2" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_af79eea3-9ed3-4aa1-8ec3-58052288da3e"> <div class="sli-field-a674d344-40f8-4032-bae2-d5a5996ff73a sli-form-field sli-element" data-ignite-field-id="a674d344-40f8-4032-bae2-d5a5996ff73a" id="id_8e3857d6-f090-4d6e-a6ee-8fb59f42a90f"> <label class="sli-required-false sli-label" for="id_8e3857d6-f090-4d6e-a6ee-8fb59f42a90f_input" id="id_8e3857d6-f090-4d6e-a6ee-8fb59f42a90f_label">Seniors (over age 60)</label> <div class="sli-select-radio sli-orientation-vertical" id="id_8e3857d6-f090-4d6e-a6ee-8fb59f42a90f_input" salsa-reference-name="scf_seniors_over_age_60_"> <label class="sli-label" for="id_8e3857d6-f090-4d6e-a6ee-8fb59f42a90f_Yes"><input data-ignite-field-id="a674d344-40f8-4032-bae2-d5a5996ff73a" id="id_8e3857d6-f090-4d6e-a6ee-8fb59f42a90f_Yes" type="radio" name="field-a674d344-40f8-4032-bae2-d5a5996ff73a" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_8e3857d6-f090-4d6e-a6ee-8fb59f42a90f_No"><input data-ignite-field-id="a674d344-40f8-4032-bae2-d5a5996ff73a" id="id_8e3857d6-f090-4d6e-a6ee-8fb59f42a90f_No" type="radio" name="field-a674d344-40f8-4032-bae2-d5a5996ff73a" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_cadbbd2a-2cba-4d42-bd8d-f5bad790eed9"> <div class="sli-field-2e27f7e4-3a0d-41f0-83bf-3444b7c81ae5 sli-form-field sli-element" data-ignite-field-id="2e27f7e4-3a0d-41f0-83bf-3444b7c81ae5" id="id_6c5836d3-097b-4039-8f6b-7403f18dccd4"> <label class="sli-required-false sli-label" for="id_6c5836d3-097b-4039-8f6b-7403f18dccd4_input" id="id_6c5836d3-097b-4039-8f6b-7403f18dccd4_label">Gay/Bisexual Men</label> <div class="sli-select-radio sli-orientation-vertical" id="id_6c5836d3-097b-4039-8f6b-7403f18dccd4_input" salsa-reference-name="scf_gay_bisexual_men"> <label class="sli-label" for="id_6c5836d3-097b-4039-8f6b-7403f18dccd4_Yes"><input data-ignite-field-id="2e27f7e4-3a0d-41f0-83bf-3444b7c81ae5" id="id_6c5836d3-097b-4039-8f6b-7403f18dccd4_Yes" type="radio" name="field-2e27f7e4-3a0d-41f0-83bf-3444b7c81ae5" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_6c5836d3-097b-4039-8f6b-7403f18dccd4_No"><input data-ignite-field-id="2e27f7e4-3a0d-41f0-83bf-3444b7c81ae5" id="id_6c5836d3-097b-4039-8f6b-7403f18dccd4_No" type="radio" name="field-2e27f7e4-3a0d-41f0-83bf-3444b7c81ae5" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_fa1db369-90a9-4e4a-bfcf-38018aff28a5"> <div class="sli-field-b308793b-660e-4482-9cfc-6bae5722f934 sli-form-field sli-element" data-ignite-field-id="b308793b-660e-4482-9cfc-6bae5722f934" id="id_f7ef710f-649c-4095-a6c8-a324799073e0"> <label class="sli-required-false sli-label" for="id_f7ef710f-649c-4095-a6c8-a324799073e0_input" id="id_f7ef710f-649c-4095-a6c8-a324799073e0_label">Bisexuals</label> <div class="sli-select-radio sli-orientation-vertical" id="id_f7ef710f-649c-4095-a6c8-a324799073e0_input" salsa-reference-name="scf_bisexuals"> <label class="sli-label" for="id_f7ef710f-649c-4095-a6c8-a324799073e0_Yes"><input data-ignite-field-id="b308793b-660e-4482-9cfc-6bae5722f934" id="id_f7ef710f-649c-4095-a6c8-a324799073e0_Yes" type="radio" name="field-b308793b-660e-4482-9cfc-6bae5722f934" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_f7ef710f-649c-4095-a6c8-a324799073e0_No"><input data-ignite-field-id="b308793b-660e-4482-9cfc-6bae5722f934" id="id_f7ef710f-649c-4095-a6c8-a324799073e0_No" type="radio" name="field-b308793b-660e-4482-9cfc-6bae5722f934" value="false" /> No</label> </div> </div> </div> </div> <div class="sli-row" id="id_93dde939-66d0-4667-8741-8a4352ab157e"> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_0509dccd-386b-4ad4-9c4a-6c6906f4455c"> <div class="sli-field-d593a262-dbac-4c6e-8cc3-a0cd286317f0 sli-form-field sli-element" data-ignite-field-id="d593a262-dbac-4c6e-8cc3-a0cd286317f0" id="id_e04f30e2-171f-42a1-8e43-ea4560f13d6d"> <label class="sli-required-false sli-label" for="id_e04f30e2-171f-42a1-8e43-ea4560f13d6d_input" id="id_e04f30e2-171f-42a1-8e43-ea4560f13d6d_label">Lesbians</label> <div class="sli-select-radio sli-orientation-vertical" id="id_e04f30e2-171f-42a1-8e43-ea4560f13d6d_input" salsa-reference-name="scf_lesbians"> <label class="sli-label" for="id_e04f30e2-171f-42a1-8e43-ea4560f13d6d_Yes"><input data-ignite-field-id="d593a262-dbac-4c6e-8cc3-a0cd286317f0" id="id_e04f30e2-171f-42a1-8e43-ea4560f13d6d_Yes" type="radio" name="field-d593a262-dbac-4c6e-8cc3-a0cd286317f0" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_e04f30e2-171f-42a1-8e43-ea4560f13d6d_No"><input data-ignite-field-id="d593a262-dbac-4c6e-8cc3-a0cd286317f0" id="id_e04f30e2-171f-42a1-8e43-ea4560f13d6d_No" type="radio" name="field-d593a262-dbac-4c6e-8cc3-a0cd286317f0" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_14cd6412-22d2-425c-b915-e570ed1ef9bb"> <div class="sli-field-b13efc9b-1841-4213-b7ff-2a0392bd77b4 sli-form-field sli-element" data-ignite-field-id="b13efc9b-1841-4213-b7ff-2a0392bd77b4" id="id_43c2bb54-157c-4692-9636-0dadf5ba0238"> <label class="sli-required-false sli-label" for="id_43c2bb54-157c-4692-9636-0dadf5ba0238_input" id="id_43c2bb54-157c-4692-9636-0dadf5ba0238_label">Transgender Men/Women</label> <div class="sli-select-radio sli-orientation-vertical" id="id_43c2bb54-157c-4692-9636-0dadf5ba0238_input" salsa-reference-name="scf_transgender_men_women"> <label class="sli-label" for="id_43c2bb54-157c-4692-9636-0dadf5ba0238_Yes"><input data-ignite-field-id="b13efc9b-1841-4213-b7ff-2a0392bd77b4" id="id_43c2bb54-157c-4692-9636-0dadf5ba0238_Yes" type="radio" name="field-b13efc9b-1841-4213-b7ff-2a0392bd77b4" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_43c2bb54-157c-4692-9636-0dadf5ba0238_No"><input data-ignite-field-id="b13efc9b-1841-4213-b7ff-2a0392bd77b4" id="id_43c2bb54-157c-4692-9636-0dadf5ba0238_No" type="radio" name="field-b13efc9b-1841-4213-b7ff-2a0392bd77b4" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_4a12fad5-fadb-489a-ad9f-b7301dace40d"> <div class="sli-field-77a75a2c-6c2b-4792-a5e8-0fef398da4e5 sli-form-field sli-element" data-ignite-field-id="77a75a2c-6c2b-4792-a5e8-0fef398da4e5" id="id_56b774e7-978b-4445-9c05-0329a871a1c2"> <label class="sli-required-false sli-label" for="id_56b774e7-978b-4445-9c05-0329a871a1c2_input" id="id_56b774e7-978b-4445-9c05-0329a871a1c2_label">Heterosexual Allies</label> <div class="sli-select-radio sli-orientation-vertical" id="id_56b774e7-978b-4445-9c05-0329a871a1c2_input" salsa-reference-name="scf_heterosexual_allies"> <label class="sli-label" for="id_56b774e7-978b-4445-9c05-0329a871a1c2_Yes"><input data-ignite-field-id="77a75a2c-6c2b-4792-a5e8-0fef398da4e5" id="id_56b774e7-978b-4445-9c05-0329a871a1c2_Yes" type="radio" name="field-77a75a2c-6c2b-4792-a5e8-0fef398da4e5" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_56b774e7-978b-4445-9c05-0329a871a1c2_No"><input data-ignite-field-id="77a75a2c-6c2b-4792-a5e8-0fef398da4e5" id="id_56b774e7-978b-4445-9c05-0329a871a1c2_No" type="radio" name="field-77a75a2c-6c2b-4792-a5e8-0fef398da4e5" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_6d7770f7-a600-41f7-abea-fa2d4f0893ab"> <div class="sli-field-26561a94-eef3-4440-904d-23f732310bad sli-form-field sli-element" data-ignite-field-id="26561a94-eef3-4440-904d-23f732310bad" id="id_88b10ce6-404a-4218-b991-25c59364503d"> <label class="sli-required-false sli-label" for="id_88b10ce6-404a-4218-b991-25c59364503d_input" id="id_88b10ce6-404a-4218-b991-25c59364503d_label">African-Americans/Blacks</label> <div class="sli-select-radio sli-orientation-vertical" id="id_88b10ce6-404a-4218-b991-25c59364503d_input" salsa-reference-name="scf_african_americans_blacks"> <label class="sli-label" for="id_88b10ce6-404a-4218-b991-25c59364503d_Yes"><input data-ignite-field-id="26561a94-eef3-4440-904d-23f732310bad" id="id_88b10ce6-404a-4218-b991-25c59364503d_Yes" type="radio" name="field-26561a94-eef3-4440-904d-23f732310bad" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_88b10ce6-404a-4218-b991-25c59364503d_No"><input data-ignite-field-id="26561a94-eef3-4440-904d-23f732310bad" id="id_88b10ce6-404a-4218-b991-25c59364503d_No" type="radio" name="field-26561a94-eef3-4440-904d-23f732310bad" value="false" /> No</label> </div> </div> </div> </div> <div class="sli-row" id="id_5c6dc956-a0f3-4e11-b8f0-396041495e6c"> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_5336cbc8-5f57-4bd3-873d-59c0e7bada27"> <div class="sli-field-af7fead5-755a-4051-b23d-7a631abc7cee sli-form-field sli-element" data-ignite-field-id="af7fead5-755a-4051-b23d-7a631abc7cee" id="id_46fcd4ff-af18-4314-868d-25caa79f1403"> <label class="sli-required-false sli-label" for="id_46fcd4ff-af18-4314-868d-25caa79f1403_input" id="id_46fcd4ff-af18-4314-868d-25caa79f1403_label">Hispanics/Latinos</label> <div class="sli-select-radio sli-orientation-vertical" id="id_46fcd4ff-af18-4314-868d-25caa79f1403_input" salsa-reference-name="scf_hispanics_latinos"> <label class="sli-label" for="id_46fcd4ff-af18-4314-868d-25caa79f1403_Yes"><input data-ignite-field-id="af7fead5-755a-4051-b23d-7a631abc7cee" id="id_46fcd4ff-af18-4314-868d-25caa79f1403_Yes" type="radio" name="field-af7fead5-755a-4051-b23d-7a631abc7cee" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_46fcd4ff-af18-4314-868d-25caa79f1403_No"><input data-ignite-field-id="af7fead5-755a-4051-b23d-7a631abc7cee" id="id_46fcd4ff-af18-4314-868d-25caa79f1403_No" type="radio" name="field-af7fead5-755a-4051-b23d-7a631abc7cee" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_285dba17-592a-4ae2-b069-bd4d40cbb2b9"> <div class="sli-field-47036432-1be1-4ff6-8ff0-9ab3167d76e6 sli-form-field sli-element" data-ignite-field-id="47036432-1be1-4ff6-8ff0-9ab3167d76e6" id="id_1dfaa668-092d-45ad-8694-7624f09dfe41"> <label class="sli-required-false sli-label" for="id_1dfaa668-092d-45ad-8694-7624f09dfe41_input" id="id_1dfaa668-092d-45ad-8694-7624f09dfe41_label">Asian/Pacific Islanders</label> <div class="sli-select-radio sli-orientation-vertical" id="id_1dfaa668-092d-45ad-8694-7624f09dfe41_input" salsa-reference-name="scf_asian_pacific_islanders"> <label class="sli-label" for="id_1dfaa668-092d-45ad-8694-7624f09dfe41_Yes"><input data-ignite-field-id="47036432-1be1-4ff6-8ff0-9ab3167d76e6" id="id_1dfaa668-092d-45ad-8694-7624f09dfe41_Yes" type="radio" name="field-47036432-1be1-4ff6-8ff0-9ab3167d76e6" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_1dfaa668-092d-45ad-8694-7624f09dfe41_No"><input data-ignite-field-id="47036432-1be1-4ff6-8ff0-9ab3167d76e6" id="id_1dfaa668-092d-45ad-8694-7624f09dfe41_No" type="radio" name="field-47036432-1be1-4ff6-8ff0-9ab3167d76e6" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_81e4bc65-adba-4228-86a8-92061a8e614b"> <div class="sli-field-65144038-5f6c-4857-8cb4-8d123ac49890 sli-form-field sli-element" data-ignite-field-id="65144038-5f6c-4857-8cb4-8d123ac49890" id="id_652fc0fb-30d8-4fc6-8b8e-ba1461b55e3b"> <label class="sli-required-false sli-label" for="id_652fc0fb-30d8-4fc6-8b8e-ba1461b55e3b_input" id="id_652fc0fb-30d8-4fc6-8b8e-ba1461b55e3b_label">Native Americans/Alaska Natives</label> <div class="sli-select-radio sli-orientation-vertical" id="id_652fc0fb-30d8-4fc6-8b8e-ba1461b55e3b_input" salsa-reference-name="scf_native_americans_alaska_natives"> <label class="sli-label" for="id_652fc0fb-30d8-4fc6-8b8e-ba1461b55e3b_Yes"><input data-ignite-field-id="65144038-5f6c-4857-8cb4-8d123ac49890" id="id_652fc0fb-30d8-4fc6-8b8e-ba1461b55e3b_Yes" type="radio" name="field-65144038-5f6c-4857-8cb4-8d123ac49890" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_652fc0fb-30d8-4fc6-8b8e-ba1461b55e3b_No"><input data-ignite-field-id="65144038-5f6c-4857-8cb4-8d123ac49890" id="id_652fc0fb-30d8-4fc6-8b8e-ba1461b55e3b_No" type="radio" name="field-65144038-5f6c-4857-8cb4-8d123ac49890" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_85f36194-4a37-4058-9580-32e9823b7704"> <div class="sli-field-ccb8ea7e-a536-42b2-8dc8-0edf4dddfa8f sli-form-field sli-element" data-ignite-field-id="ccb8ea7e-a536-42b2-8dc8-0edf4dddfa8f" id="id_6c4fec96-205b-4719-b329-191caffb93ca"> <label class="sli-required-false sli-label" for="id_6c4fec96-205b-4719-b329-191caffb93ca_input" id="id_6c4fec96-205b-4719-b329-191caffb93ca_label">Immigrants/Refugees</label> <div class="sli-select-radio sli-orientation-vertical" id="id_6c4fec96-205b-4719-b329-191caffb93ca_input" salsa-reference-name="scf_immigrants_refugees"> <label class="sli-label" for="id_6c4fec96-205b-4719-b329-191caffb93ca_Yes"><input data-ignite-field-id="ccb8ea7e-a536-42b2-8dc8-0edf4dddfa8f" id="id_6c4fec96-205b-4719-b329-191caffb93ca_Yes" type="radio" name="field-ccb8ea7e-a536-42b2-8dc8-0edf4dddfa8f" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_6c4fec96-205b-4719-b329-191caffb93ca_No"><input data-ignite-field-id="ccb8ea7e-a536-42b2-8dc8-0edf4dddfa8f" id="id_6c4fec96-205b-4719-b329-191caffb93ca_No" type="radio" name="field-ccb8ea7e-a536-42b2-8dc8-0edf4dddfa8f" value="false" /> No</label> </div> </div> </div> </div> <div class="sli-row" id="id_78f32ee4-605e-49bd-aab5-f80bca60a14f"> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_4b7f3c09-ff1c-4b64-af9e-66a7a160c781"> <div class="sli-field-b2f2c83d-8132-4d84-b36d-7509ae2bb110 sli-form-field sli-element" data-ignite-field-id="b2f2c83d-8132-4d84-b36d-7509ae2bb110" id="id_fa3d3257-938d-4b77-9b2c-d23e9c30f137"> <label class="sli-required-false sli-label" for="id_fa3d3257-938d-4b77-9b2c-d23e9c30f137_input" id="id_fa3d3257-938d-4b77-9b2c-d23e9c30f137_label">Substance Users</label> <div class="sli-select-radio sli-orientation-vertical" id="id_fa3d3257-938d-4b77-9b2c-d23e9c30f137_input" salsa-reference-name="scf_substance_users"> <label class="sli-label" for="id_fa3d3257-938d-4b77-9b2c-d23e9c30f137_Yes"><input data-ignite-field-id="b2f2c83d-8132-4d84-b36d-7509ae2bb110" id="id_fa3d3257-938d-4b77-9b2c-d23e9c30f137_Yes" type="radio" name="field-b2f2c83d-8132-4d84-b36d-7509ae2bb110" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_fa3d3257-938d-4b77-9b2c-d23e9c30f137_No"><input data-ignite-field-id="b2f2c83d-8132-4d84-b36d-7509ae2bb110" id="id_fa3d3257-938d-4b77-9b2c-d23e9c30f137_No" type="radio" name="field-b2f2c83d-8132-4d84-b36d-7509ae2bb110" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_6da2586f-31e2-47b9-8283-cb78674ca2b7"> <div class="sli-field-41782514-065a-49f0-96a1-061269cd3c87 sli-form-field sli-element" data-ignite-field-id="41782514-065a-49f0-96a1-061269cd3c87" id="id_1429952c-7798-4b3f-a78f-a0c420624ac2"> <label class="sli-required-false sli-label" for="id_1429952c-7798-4b3f-a78f-a0c420624ac2_input" id="id_1429952c-7798-4b3f-a78f-a0c420624ac2_label">Sex Workers</label> <div class="sli-select-radio sli-orientation-vertical" id="id_1429952c-7798-4b3f-a78f-a0c420624ac2_input" salsa-reference-name="scf_sex_workers"> <label class="sli-label" for="id_1429952c-7798-4b3f-a78f-a0c420624ac2_Yes"><input data-ignite-field-id="41782514-065a-49f0-96a1-061269cd3c87" id="id_1429952c-7798-4b3f-a78f-a0c420624ac2_Yes" type="radio" name="field-41782514-065a-49f0-96a1-061269cd3c87" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_1429952c-7798-4b3f-a78f-a0c420624ac2_No"><input data-ignite-field-id="41782514-065a-49f0-96a1-061269cd3c87" id="id_1429952c-7798-4b3f-a78f-a0c420624ac2_No" type="radio" name="field-41782514-065a-49f0-96a1-061269cd3c87" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_ab1dc0ea-7341-459e-a87a-121b381d34c0"> <div class="sli-field-1fe0f71b-dc13-4f77-87bd-79aed1d4368a sli-form-field sli-element" data-ignite-field-id="1fe0f71b-dc13-4f77-87bd-79aed1d4368a" id="id_39241e6b-69dd-4a52-bf41-67b82e877b33"> <label class="sli-required-false sli-label" for="id_39241e6b-69dd-4a52-bf41-67b82e877b33_input" id="id_39241e6b-69dd-4a52-bf41-67b82e877b33_label">Incarcerated/Formerly Incarcerated Persons</label> <div class="sli-select-radio sli-orientation-vertical" id="id_39241e6b-69dd-4a52-bf41-67b82e877b33_input" salsa-reference-name="scf_incarcerated_formerly_incarcerated_persons"> <label class="sli-label" for="id_39241e6b-69dd-4a52-bf41-67b82e877b33_Yes"><input data-ignite-field-id="1fe0f71b-dc13-4f77-87bd-79aed1d4368a" id="id_39241e6b-69dd-4a52-bf41-67b82e877b33_Yes" type="radio" name="field-1fe0f71b-dc13-4f77-87bd-79aed1d4368a" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_39241e6b-69dd-4a52-bf41-67b82e877b33_No"><input data-ignite-field-id="1fe0f71b-dc13-4f77-87bd-79aed1d4368a" id="id_39241e6b-69dd-4a52-bf41-67b82e877b33_No" type="radio" name="field-1fe0f71b-dc13-4f77-87bd-79aed1d4368a" value="false" /> No</label> </div> </div> </div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_5c25ac6a-26c0-4766-b4da-d02ebebdfb3d"> <div class="sli-field-3bff2dba-41ab-4f09-b89f-7782d38c5701 sli-form-field sli-element" data-ignite-field-id="3bff2dba-41ab-4f09-b89f-7782d38c5701" id="id_2112336b-c530-46b0-ac59-2863c1d5f5f2"> <label class="sli-required-false sli-label" for="id_2112336b-c530-46b0-ac59-2863c1d5f5f2_input" id="id_2112336b-c530-46b0-ac59-2863c1d5f5f2_label">Individuals with Disabilities</label> <div class="sli-select-radio sli-orientation-vertical" id="id_2112336b-c530-46b0-ac59-2863c1d5f5f2_input" salsa-reference-name="scf_individuals_with_disabilities"> <label class="sli-label" for="id_2112336b-c530-46b0-ac59-2863c1d5f5f2_Yes"><input data-ignite-field-id="3bff2dba-41ab-4f09-b89f-7782d38c5701" id="id_2112336b-c530-46b0-ac59-2863c1d5f5f2_Yes" type="radio" name="field-3bff2dba-41ab-4f09-b89f-7782d38c5701" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_2112336b-c530-46b0-ac59-2863c1d5f5f2_No"><input data-ignite-field-id="3bff2dba-41ab-4f09-b89f-7782d38c5701" id="id_2112336b-c530-46b0-ac59-2863c1d5f5f2_No" type="radio" name="field-3bff2dba-41ab-4f09-b89f-7782d38c5701" value="false" /> No</label> </div> </div> </div> </div> <div class="sli-row" id="id_629b9584-d547-4eed-9628-63828fb86b17"> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_d43fac14-631b-41be-bebf-63127b91464d"></div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_5b121919-b78c-42cf-b7a0-29f2baf6f8ff"></div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_5826ac70-1329-4492-b244-1c84490875d1"></div> <div class="sli-large-3 sli-medium-3 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_85456055-b369-4be2-9517-fee9eb3aeb11"></div> </div> <div class="sli-field-d73f3c2e-2f72-4075-9325-3ae1f65e4972 sli-form-field sli-element" data-ignite-field-id="d73f3c2e-2f72-4075-9325-3ae1f65e4972" id="id_1e49e2db-57c5-4fcc-846f-325205e0281d"> <label class="sli-required-false sli-label" for="id_1e49e2db-57c5-4fcc-846f-325205e0281d_input" id="id_1e49e2db-57c5-4fcc-846f-325205e0281d_label">Has your organization produced resource materials (i.e., guides, white papers, websites, curricula, etc.) that you would like to have listed as part of the Coalition's resource library?</label> <div class="sli-select-radio sli-orientation-horizontal" id="id_1e49e2db-57c5-4fcc-846f-325205e0281d_input" salsa-reference-name="scf_resources"> <label class="sli-label" for="id_1e49e2db-57c5-4fcc-846f-325205e0281d_Yes"><input data-ignite-field-id="d73f3c2e-2f72-4075-9325-3ae1f65e4972" id="id_1e49e2db-57c5-4fcc-846f-325205e0281d_Yes" type="radio" name="field-d73f3c2e-2f72-4075-9325-3ae1f65e4972" value="true" checked="checked" /> Yes</label> <label class="sli-label" for="id_1e49e2db-57c5-4fcc-846f-325205e0281d_No"><input data-ignite-field-id="d73f3c2e-2f72-4075-9325-3ae1f65e4972" id="id_1e49e2db-57c5-4fcc-846f-325205e0281d_No" type="radio" name="field-d73f3c2e-2f72-4075-9325-3ae1f65e4972" value="false" /> No</label> </div> </div> </div> </div> <div class="sli-row" id="id_165440bc-80b4-4a49-90d2-b54667396f51"> <div class="sli-large-12 sli-medium-12 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_a62d241b-b69c-4d3f-92a6-dea66d86948d"> <div class="sli-row" id="id_36968edc-f3d2-4b34-931d-9965d74efa1a"> <div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns " data-ignite-container-type="DEFAULT" id="id_010e6a9f-e78b-4b56-9368-a71ae5de708f"> <div class="sli-field-6b13ef4e-7e28-44f6-a2b7-1cf5cfd37d52 sli-form-field sli-element" data-ignite-field-id="6b13ef4e-7e28-44f6-a2b7-1cf5cfd37d52" id="id_cfb3126e-6915-4069-9bb2-436f3c655e65"> <label class="sli-required-false sli-label" for="id_cfb3126e-6915-4069-9bb2-436f3c655e65_input" id="id_cfb3126e-6915-4069-9bb2-436f3c655e65_label">Are you a provider?</label> <select class="sli-select-6b13ef4e-7e28-44f6-a2b7-1cf5cfd37d52 sli-input" name="field-6b13ef4e-7e28-44f6-a2b7-1cf5cfd37d52" data-ignite-field-id="6b13ef4e-7e28-44f6-a2b7-1cf5cfd37d52" id="id_cfb3126e-6915-4069-9bb2-436f3c655e65_input" salsa-reference-name="scf_are_you_a_provider_"><option value="" selected="selected">Choose one...</option><option value="DO">DO</option><option value="MD">MD</option><option value="NP">NP</option><option value="PA">PA</option><option value="PharmD">PharmD</option><option value="DDS">DDS</option><option value="RN">RN</option><option value="Substance Abuse Counselor">Substance Abuse Counselor</option><option value="Mental Health Counselor">Mental Health Counselor</option><option value="Acupuncturist">Acupuncturist</option><option value="Chiropractor">Chiropractor</option><option value="PT">PT</option><option value="PT Asst">PT Asst</option><option value="OT">OT</option><option value="OT Asst">OT Asst</option><option value="Dance Therapist">Dance Therapist</option><option value="Dietitian">Dietitian</option><option value="Massage Therapist">Massage Therapist</option><option value="Naturopath">Naturopath</option><option value="Nutritionist">Nutritionist</option><option value="Recreation Therapist">Recreation Therapist</option><option value="Podiatrist">Podiatrist</option><option value="Resident/Fellow">Resident/Fellow</option><option value="Nurse Anesthetist">Nurse Anesthetist</option><option value="CNS">CNS</option><option value="LPN">LPN</option><option value="Trained Medication Employee">Trained Medication Employee</option><option value="Therapeutic Pharm Agnt">Therapeutic Pharm Agnt</option><option value="Pharm Tech">Pharm Tech</option><option value="Pharmacist">Pharmacist</option><option value="Pharm Detailers">Pharm Detailers</option><option value="Pharm Intern">Pharm Intern</option><option value="Ind Clinical SLWKR">Ind Clinical SLWKR</option><option value="Ind SLWKR">Ind SLWKR</option><option value="LPC">LPC</option><option value="Marriage and Family Therapist">Marriage and Family Therapist</option><option value="Psychologist">Psychologist</option><option value="Psychology Assoc">Psychology Assoc</option><option value="SWLK Assoc">SWLK Assoc</option><option value="Supervised Practice Psychol">Supervised Practice Psychol</option><option value="Cert Addiction Counselor I">Cert Addiction Counselor I</option><option value="Cert Addiction Counselor II">Cert Addiction Counselor II</option><option value="Substance Use Provider">Substance Use Provider</option><option value="Other">Other</option><option value="I am not a licensed provider.">I am not a licensed provider.</option></select> </div> </div> <div class="sli-large-6 sli-medium-6 sli-small-12 sli-columns sli-end " data-ignite-container-type="DEFAULT" id="id_feac7092-db3a-4214-89d0-473c8fff21ea"> <div class="sli-field-da13477f-f923-4110-b553-cd958fbf1106 sli-form-field sli-element" data-ignite-field-id="da13477f-f923-4110-b553-cd958fbf1106" id="id_7df1f92d-a655-4049-910c-22e4db6483c1"> <label class="sli-required-false sli-label" for="id_7df1f92d-a655-4049-910c-22e4db6483c1_input" id="id_7df1f92d-a655-4049-910c-22e4db6483c1_label">Do you provide HIV Services?</label> <div class="sli-select-radio sli-orientation-vertical" id="id_7df1f92d-a655-4049-910c-22e4db6483c1_input" salsa-reference-name="scf_do_you_provide_hiv_services_"> <label class="sli-label" for="id_7df1f92d-a655-4049-910c-22e4db6483c1_No, I do not currently/have never provided HIV-related services"><input data-ignite-field-id="da13477f-f923-4110-b553-cd958fbf1106" 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