EDI Form
How do you best identify your ethno-cultural region?
Africa - Northern (Sudan, Libya)
Africa - Central (Cameron, Chad, Congo Republic)
Africa - East (Eritrea, Ethiopia, Kenya, Rwanda, Somalia, Uganda, Tanzania, Madagascar)
Africa - South (Angola, Batswana, Mozambique, S Africa, Zambia, Zimbabwe, Swaziland)
Africa - Western (Algeria, Liberia, Guinea, Senegal, Sierra Leone, Mali)
America - Central America
America - North America (US, Canada, Newfoundland, Greenland)
America - South America
America - American Indian or Alaska Native – Iroquois, Cherokee, Navajo, Haida etc
Asia - East Asia (Korean, Japanese, China, Hong Kong, Tibetan, Mongolian, Taiwanese)
Asia - South Asia (India, Nepal, Pakistan, Bangladesh)
Asia - Southwest Asia (Vietnam, Laos, Myanmar, Thailand, Sri Lanka)
Carribbean Descent
Europe - Central (Italy, Germany, Netherlands, Switzerland)
Europe - Western (France, Germany, Spain, Belgium, Portugal, Austria)
Europe - Eastern European (Austria,Poland, Russia, Slavic countries)
Europe - Northern European (Scandinavian Countries, Iceland, Northern Ireland, England, Scotland, and Wales)
Middle East (Afghanistan, Israel, Egypt, Syria, UAE, Yemen, Qatar, Turkey, Saudi Arabia, Jordan, Iraq, Iran, Kuwait)
Oceania - (New Zealand, Australia, and Papua New Guinea)
Pacific Region - Pacific Islander or Hawaiian – Samoan, Tongan, Maori, Tahitian, etc
Pacific Region - South Pacific (Indonesia, Philippines, and Solomon Islands)
West Indies - (Caribbean Sea, Latin American, US Virgin Islands, Antilles, etc)
Other
If other, please describe
How do you best describe your gender identity/expression?
What religion or spiritual beliefs best describes you?
Agnostic
Amish
Buddhist
Roman Catholic
Christianity
Church of God
Hindu
Islam
Jehovah's Witness
Jewish
Scientology
Shinto
Taoist
Unitarian
Zionist
Other
None
Prefer not to Say
If other, please describe
Do you have a disability?
Yes
No
Prefer not to Say
How do you best describe your economic class?
How do you best describe your sexual orientation?
Professional Activities (select all that apply):
Clinical
Administrative
Education/Teaching
Research
Supervision
Consultation
Other
If other, please describe
Primary Focus of Interest/Expertise from an advocacy perspective:
Clinical BSM
Health Psychology
Sleep Disparities
Nursing (NP, RN, LPN, DNP)
Licensed Clinical Social Work (LCSW)
Rehab/OT/PT/SLT
RPSGT
Psychiatry
Sleep Medicine
Clinical Practice and Research
Education/Teaching
Supervision/Consultation
Administrative
Other
If other, please describe
Research
Grantsmanship
Scientific Writing
Clinical trial design and implementation
Dissemination and implementation science
Quantitative methods
Qualitative methods
Other
If other, please describe
How interested are you in being part of an EDI Workgroup?
Very interested
Moderately interested
Not interested
If participating in an EDI workgroup, what is your availability to meet?
Monthly
Bi-Weekly
Other
If other, please describe
If participating in an EDT workgroup, what format would be best to meet?
60-90 minute combination of working and status update meetings
30-60 minute status update meetings, with work completed outside meeting time
Submit
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