Additional Questions
Will you be attending the complimentary session Morning of Culture: Education and Networking for Black/African American IBD Patients and Caregivers?
Do you have a connection to Crohn's or ulcerative colitis?
[Select...]
Yes
No
If yes, what is your connection:
If connection to Crohn's or ulcerative colitis is Other, please specify:
Were you or your loved one diagnosed in the last year?
[Select...]
Yes
No
On a scale from 0 to 10, with 0 indicating no knowledge and 10 indicating expert knowledge, how would you rate your knowledge about how to reach and stay in remission?
[Select...]
0 No knowledge
1
2
3
4
5
6
7
8
9
10 Expert Knowledge
On a scale from 0 to 10, with 0 indicating not aware at all and 10 indicating extremely aware, how would you rate your level of awareness about resources for IBD?
[Select...]
0 Not aware at all
1
2
3
4
5
6
7
8
9
10 Extremely aware
How confident are you that you can control and manage most of your health problems related to IBD?
[Select...]
0 Not confident at all
1
2
3
4
5
6
7
8
9
10 Very confident
To which gender do you most identify?
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
If gender identity is Other, please specify:
Please indicate your age.
[Select...]
Under 18 years old
19 - 24 years old
25 - 34 years old
35 - 44 years old
45 - 54 years old
55 - 64 years old
65 - 74 years old
75 years and over
Prefer not to say
What is your race? Please select all that apply:
If Race is Other, please specify
What is your ethnicity?
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Is this your first Crohn's & Colitis Foundation education program?
[Select...]
Yes
No
How did you hear about our program?
Are you involved with the local chapter?
[Select...]
Yes
No
Are you bringing additional guests? If yes, how many?
[Select...]
1
2
3
4
Guest 1 Name
Guest 1 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 1 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 1 Race
Guest 1 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 1 Name
Guest 1 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 1 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 1 Race
Guest 1 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 2 Name
Guest 2 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 2 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 2 Race
Guest 2 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 1 Name
Guest 1 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 1 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 1 Race
Guest 1 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 2 Name
Guest 2 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 2 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 2 Race
Guest 2 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 3 Name
Guest 3 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 3 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 3 Race
Guest 3 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 1 Name
Guest 1 Gender
[Select...]
Female
Male
Non-binary
Other
Guest 1 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 1 Race
Guest 1 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 2 Name
Guest 2 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 2 Race
Guest 2 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 2 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 3 Name
Guest 3 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 3 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 3 Race
Guest 3 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
Guest 4 Name
Guest 4 Gender
[Select...]
Female
Male
Non-binary
Other
Prefer not to disclose
Guest 4 Ethnicity
[Select...]
Hispanic or Latino
Not Hispanic or Latino
Prefer not to disclose
Guest 4 Race
Guest 4 Age
[Select...]
Under 18 years old
19-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years and over
Prefer not to say
We provide various food options at our programs, but if you have specific needs, you’re welcome to bring your own items. To help us plan, do you have any of the following dietary restrictions?
