This form is used by students choosing to participate in an opt in experience to learn about abortion care experientially through a one day opt in experience on the clerkship. Students specify their desired level of involvement for each component as “yes”, “no”, or “not sure.” Students may choose from a full spectrum of activities from observation to participation. Students then bring the completed form with them to clinic where their responses are reviewed and their ability to expand or limit their participation at any time is affirmed.