MVS Clinician Form - OhioGuidestone Research Portal

Maternal Vitality Study- Clinician Information Sheet *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Professional Licensure & Certification

(e.g. MSW, LISW)

Next Steps: Meeting Availability

Weekdays, Morning (8am-12pm)
Weekdays, Afternoons (12pm-4pm)
Weekdays, Evenings (5pm-7:30pm)
Saturdays, Morning (9am-12pm)
Saturdays, Afternoon (12pm-3pm)

Please mark your general availability for your introductory meeting and/or training meeting (if you have not already attended).

Next Steps: General Availability for Study Sessions with Participating Moms

Weekdays, Morning (8am-12pm)
Weekdays, Afternoons (12pm-4pm)
Weekdays, Evenings (5pm-7:30pm)
Saturdays, Morning (9am-12pm)
Saturdays, Afternoon (12pm-3pm)

Please mark your general availability for study sessions with participating moms. The research assistant team will facilitate scheduling appointments and setting up Teams links for you.

Positionality Statement

Please write a statement sharing your social identity as it relates to the project (e.g. working with perinatal Black/African American women in greater Cleveland).

File Upload

Click or drag a file to this area to upload.

Please upload your completed W-9 Form here. Access the document here: https://www.irs.gov/pub/irs-pdf/fw9.pdf