JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Free Plan B
IHRC is happy to offer free Plan B to those who so seek it! Please fill out the following form.
Disclaimer: All information collected is used for delivery and research purposes and will be kept confidential!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name (First three letters of your first name and first three of your last name, in order to remain anonymous, ex. IOW HAR)
*
Your answer
Date of Birth (ex. 01/02/1934)
*
Your answer
Gender
Man (1)
Woman (2)
Trans(Masc) (3)
Trans(Fem) (4)
Non-binary (5)
Clear selection
ID Number: (Use the
FIRST
and
THIRD
letters of your
FIRST
and
LAST
name followed by your date of birth, followed by the number corresponding with your gender. Ex. IWHR010219345 This helps you remain anonymous in our research database)
Your answer
Race
*
White/Caucasian
Black
Asian/Pacific Islander
Indigeonous
Other:
Required
Ethnicity
Latino
Non-latino
Other:
Clear selection
Please state how you would like to receive your Plan B:
*
Pickup
Delivery (Same Day or Next Day)
Shipment (3 Days to a Few Weeks)
Next
Page 1 of 2
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
