all repos — nshc-form @ 61a4a075b712efd02c2b50a0fc2b04a211ac21f5

northstar health collective feedback form

templates/form.html

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</head>

<h1>Accountability For Medics</h1>
<p>Have you had an encounter with a medic that made you feel uncomfortable? We know that we are in the work of building community care for the long-haul. We know that racism and oppression exist in all levels of our society, and that our revolutionary work is to continue to disrupt them everywhere - including in our own bodies. Are there things we should know? We are open to hearing about about negative, uncomfortable, or hurtful experiences with medics you've encountered so we can continue to build a movement that is grounded in healing, not continuing to replicate systemic violence.</p>
<p>North Star Health Collective is one of many groups using the name ‘medic’ in the Twin Cities in the last week.    We endeavor to be accountable to our community.    This information will be used to start conversations with the persons involved if we are able to identify them and to hold medics operating as part of NSHC to the agreements and protocols discussed in the vetting process.</p>
<p>This form is anonymous and you do not have to leave us any identifying information. If you would like us to follow up with you, please feel free to leave contact information. If you don't want to do that, please leave it blank.</p>
<form action="/" method="POST" novalidate>
  <div>
    <p><label>If you're a medic, did you or your medic buddy do something that made you uncomfortable?</label></p>
    <p><textarea placeholder="Please describe to the best of your ability. Our goal is not to repeat the work of the carceral state, but to help hold each other accountability and support deep reflection and change in all the medics we are working with in the field." name="question1"></textarea></p>
  </div>
  <div>
    <p><label>Are there things you would like to see Northstar do differently to better care for, and support our communities?</label></p>
    <p><textarea name="question2"></textarea></p>
  </div>
  <div>
    <p><label>Have you had an encounter with a medic that made you feel uncomfortable or disrespected?</label></p>
    <p><textarea placeholder="Please tell us about the interaction. What happened? Where and when did this occur? Please be as specific as you are comfortable being" name="question3"></textarea></p>
  </div>
  <div>
    <p><label>Do you want us to follow up with a specific person re: accountability?</label></p>
    <p><textarea placeholder="We are thinking critically about people's safety and the use of identifying information. If you do not feel comfortable calling us directly (which would mean we'd have have your phone or email), please leave as little information as we would need here. Perhaps a phone number or a first name or the site they were located at. We want to balance, as best we can, protecting the security of all who we work with." name="question4"></textarea></p>
  </div>
  <div>
    <p><label>Are there any other comments you would like to share with us?</label></p>
    <p><textarea name="question5"></textarea></p>
  </div>
  <div>
    <p><label>Would you like us to follow up with you? If yes, please leave your phone number or email here:</label></p>
    <p><textarea name="question6"></textarea></p>
  </div>
  <div>
    <p><label>Anything else you'd like us to know or specific requests?</label></p>
    <p><textarea name="question7"></textarea></p>
  </div>
  <div>
    <input type="submit" value="Send message">
  </div>
</form>

<footer>
  <p>hosted with love for <a href="https://northstarhealthcollective.org">North Star Health Collective</a> by <a href="https://cyberia.club">Cyberia Computer Club</a></p>
  <p>warrant canary: 🐦</p>
</footer>

</html>