*First Name:

*Last Name:

Credentials/Degrees/Certifications:

*Email Address:

*Title/Position:

*Employer/Organization Type: Community based-organization Federal government agency Foundation Healthcare-focused nonprofit organization Hospital Patient advocacy group Private practice State health department N/A-Family member interested in NICHQ's work Other

*Work State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Marshall Islands Micronesia Northern Mariana Islands Palau Puerto Rico Virgin Islands Armed Forces Americas Armed Forces Europe Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon Barnet Barnsley Bath and NE Somerset Bedfordshire Berkshire Bexley Birmingham Blackburn with Darwen Blackpool Bolton Bournemouth Bracknell Forest Bradford Brent Brighton and Hove Bristol, City of Bromley Buckinghamshire Bury Calderdale Cambridgeshire Camden Channel Isles Cheshire Cornwall Coventry Croydon Cumbria Darlington Derby Derbyshire Devon Doncaster Dorset Dudley Durham Ealing East Riding of Yorkshire East Sussex Enfield Essex Gateshead Gloucestershire Greater London Greater Manchester Greenwich Hackney Halton Hammersmith and Fulham Hampshire Haringey Harrow Hartlepool Havering Herefordshire,County of Hertfordshire Hillingdon Hounslow Isle of Man Isle of Wight Isles of Scilly Islington Kensington and Chelsea Kent Kingston upon Hull,City of Kingston upon Thames Kirklees Knowsley Lambeth Lancashire Leeds Leicester Leicestershire Lewisham Lincolnshire Liverpool London,City of Luton Manchester Medway Merseyside Merton Middlesbrough Middlesex Milton Keynes ND Sunderland Newcastle upon Tyne Newham Norfolk North East Lincolnshire North Lincolnshire North Riding of Yorkshire North Somerset North Tyneside North Yorkshire Northamptonshire Northumberland Nottingham Nottinghamshire Oldham Oxfordshire Peterborough Plymouth, England Poole Portsmouth Reading Redbridge Redcar and Cleveland Richmond upon Thames Rochdale Rotherham Rutland Salford Sandwell Sefton Sheffield Shropshire Slough Solihull Somerset South Gloucestershire South Tyneside South Yorkshire Southampton Southend-on-Sea Southwark St Helens Staffordshire Stockport Stockton-on-Tees Stoke-on-Trent Suffolk Surrey Sutton Swindon Tameside Telford and wrekin Thurrock Torbay Tower Hamlets Trafford Tyne and Wear Wakefield Walsall Waltham Forest Wandsworth Warrington Warwickshire West Berkshire West Midlands West Sussex West Yorkshire Westminster Wigan Wiltshire Windsor and Maidenhead Wirral Wokingham Wolverhampton Worcestershire York Aberdeen Aberdeenshire Angus Argyll and Bute Banffshire Clackmannanshire Dumfries and Galloway Dundee City East Ayrshire East Dunbartonshire East Lothian East Renfrewshire Edinburgh Eilean Siar Falkirk Fife Glasgow Highland Inverclyde Isle of Arran Isle of Islay Isle of Lewis Isle of Skye Midlothian Moray North Ayrshire North Lanarkshire Orkney Islands Perth and Kinross Renfrewshire Scottish Borders, The Shetland Islands South Ayrshire South Lanarkshire Stirling West Dunbartonshire West Lothian Western Isles Antrim Ards Armagh Ballymena Ballymoney Banbridge Belfast Carrickfergus Castlereagh Coleraine Cookstown Craigavon Derry Down Dungannon Fermanagh Larne Limavady Lisburn Magherafelt Moyle Newry and Mourne Newtownabbey North Down NIR Omagh Strabane Tyrone Anglesey Blaenau Gwent Bridgend Caerphilly Cardiff Carmarthenshire Ceredigion Clwyd Conwy Denbighshire Flintshire Gwynedd Merthyr Tydfil Mid Glamorgan Monmouthshire Neath Port Talbot Newport Pembrokeshire Powys Rhondda Cynon Taf South Glamorgan Swansea Torfaen Vale of Glamorgan West Glamorgan Wrexham Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia

*Years of work experience: 0-5 years 6-10 years 11-15 years 16-20 years 21+ years

NICHQ projects participated in (if any):

*Topic areas of interest: Health Equity Health Policy Healthy Living (obesity, oral health, vision and eye screening) Improvement Science Measure Development Patient and Family Engagement Quality Care (ADHD, asthma, autism, epilepsy, medical home, sickle cell disease, social-emotional development) Strong Start (breastfeeding, infant health, newborn hearing screening)

*Top reason for subscribing: Obtain resources relevant to my work Learn about webinars and learning activities Read NICHQ leaders' reflections on children’s health Find out about opportunities to join new projects I'm on an existing NICHQ-led project Other

*Primary connection to NICHQ: I turn to NICHQ for useful information and resources I have participated in a NICHQ-led online community or listserv I have participated on a team in a NICHQ-led project I have enrolled in a NICHQ fee-based program My organization/employer has partnered with NICHQ on a project My organization/employer has funded a NICHQ project Other