ATTP Application for Medical, Nursing and Allied Health Students Survey

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4. Contact Information:(State in name if Ms., Mr., or Dr.)

Contact Information:(State in name if Ms., Mr., or Dr.) Full Name:
Home Address:
Home Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

5. List professional degrees for printed certificate (if applicable):

List professional degrees for printed certificate (if applicable):

6. Your current profession: (Select one)

Your current profession: (Select one)

If Medicine or Other (please specify)

7. How did you hear about the ATTP training?(check all that apply)

How did you hear about the ATTP training?(check all that apply) NPF website NPF Parkinson Report ATTP brochure/flyer	Colleges who attended ATTP Professional org. website
Other (please specify)

8. How would you describe yourself?

How would you describe yourself? Asian Black (African American) Native American/American Indian	Native Hawaiian or Other Pacific Islander Black (non-African American) White
Other (please specify)

9. Are you of Hispanic/Latino origin?

Are you of Hispanic/Latino origin? Yes	No
If yes, country of origin:(please specify)

10. Business Information:

Business Information: Name of Primary Work Setting
Street Address:
City:
County:
State:
Zip / Postal Code:
Work Phone:
Work Fax:
Mobile Phone Number:
Work / Internship job title, if applicable:

11. Are you in a practicum that includes working in an interdisciplinary team?

Are you in a practicum that includes working in an interdisciplinary team? Yes

12. How long have you worked in an interdisciplinary team?

How long have you worked in an interdisciplinary team?

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13. If you have a license in another profession, please provide your license number, profession, and the state in which it was issued. If not, please proceed to #14.

If you have a license in another profession, please provide your license number, profession, and the state in which it was issued. If not, please proceed to #14. State or National License#:
Profession:
State issued:

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14. Undergraduate Education

Undergraduate Education Name of School:
Major and area of specialty, any:
Degree/ Diploma:
Year degree granted:

15. Graduate or Medical Education:

Graduate or Medical Education: Name of School:
Major and area of specialty, if any:
Degree/ Diploma:
Year degree granted:

16. Professional/Other School or Training:

Professional/Other School or Training: Name of School:
Major and area of specialty, if any:
Degree/ Diploma:
Year degree granted:

17. Brief description of your work and/or practicum experience (include any experience with older adults or persons with Parkinson disease and care partners—Max 250 words)

Brief description of your work and/or practicum experience (include any experience with older adults or persons with Parkinson disease and care partners—Max 250 words)

18. Have you worked with diverse racial or cultural groups?

Have you worked with diverse racial or cultural groups? Yes	No
If yes (please specify)

19. Are you currently working in medically underserved areas?

Are you currently working in medically underserved areas? Yes

20. Do you have experience with rural populations?

Do you have experience with rural populations? Yes

21. Do you have experience in working on an interdisciplinary team?

Do you have experience in working on an interdisciplinary team? Yes

22. If you are currently on an interdisciplinary team, please answer the questions below:

If you are currently on an interdisciplinary team, please answer the questions below: How long has your current interdisciplinary team been functioning?(#years)
How long have you been on this team?(#years)

23. What issues around interdisciplinary teams are of most interest to you?

What issues around interdisciplinary teams are of most interest to you?

24. Please select one number that indicates your confidence:

	Not at all confident 1	2	3	4	5	6	7	8	9	Extremely confident 10
How confident are you now in working with or treating a person with Parkinson disease?	*Please select one number that indicates your confidence: How confident are you now in working with or treating a person with Parkinson disease? Not at all confident 1	How confident are you now in working with or treating a person with Parkinson disease? 2	How confident are you now in working with or treating a person with Parkinson disease? 3	How confident are you now in working with or treating a person with Parkinson disease? 4	How confident are you now in working with or treating a person with Parkinson disease? 5	How confident are you now in working with or treating a person with Parkinson disease? 6	How confident are you now in working with or treating a person with Parkinson disease? 7	How confident are you now in working with or treating a person with Parkinson disease? 8	How confident are you now in working with or treating a person with Parkinson disease? 9	How confident are you now in working with or treating a person with Parkinson disease? Extremely confident 10
How confident are you now in working with the care partner of a person with Parkinson disease?	How confident are you now in working with the care partner of a person with Parkinson disease? Not at all confident 1	How confident are you now in working with the care partner of a person with Parkinson disease? 2	How confident are you now in working with the care partner of a person with Parkinson disease? 3	How confident are you now in working with the care partner of a person with Parkinson disease? 4	How confident are you now in working with the care partner of a person with Parkinson disease? 5	How confident are you now in working with the care partner of a person with Parkinson disease? 6	How confident are you now in working with the care partner of a person with Parkinson disease? 7	How confident are you now in working with the care partner of a person with Parkinson disease? 8	How confident are you now in working with the care partner of a person with Parkinson disease? 9	How confident are you now in working with the care partner of a person with Parkinson disease? Extremely confident 10

25. What interested you most about this training program? (Max 250 words)

What interested you most about this training program? (Max 250 words)

For more information about the ATTP program, please visit the NPF website (www.parkinson.org/attp).
We encourage to complete this application to better serve you; never the less, if you still need our traditional enrollment application, you may download it, fill it and send it electronically to: attp@parkinson.org or via fax 305-243-8274.
Questions? Contact Denise Beran Tel: 305-243-2985

Note: Registration fee is waived only for students matriculated full-time.
(You will be notified about your application by email or by phone if no email provided.)

Professional accreditation for each profession are posted on the NPF website page as listed above.

ATTP Application for Medical, Nursing and Allied Health Students

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1. Today's Date (MM/DD/YYYY):

2. I am applying for this training as

3. I am matriculated full time

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4. Contact Information:(State in name if Ms., Mr., or Dr.)

5. List professional degrees for printed certificate (if applicable):

6. Your current profession: (Select one)

7. How did you hear about the ATTP training?(check all that apply)

8. How would you describe yourself?

9. Are you of Hispanic/Latino origin?

10. Business Information:

11. Are you in a practicum that includes working in an interdisciplinary team?

12. How long have you worked in an interdisciplinary team?

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13. If you have a license in another profession, please provide your license number, profession, and the state in which it was issued. If not, please proceed to #14.

*
14. Undergraduate Education

15. Graduate or Medical Education:

16. Professional/Other School or Training:

17. Brief description of your work and/or practicum experience (include any experience with older adults or persons with Parkinson disease and care partners—Max 250 words)

18. Have you worked with diverse racial or cultural groups?

19. Are you currently working in medically underserved areas?

20. Do you have experience with rural populations?

21. Do you have experience in working on an interdisciplinary team?

22. If you are currently on an interdisciplinary team, please answer the questions below:

23. What issues around interdisciplinary teams are of most interest to you?

24. Please select one number that indicates your confidence:

25. What interested you most about this training program? (Max 250 words)

ATTP Application for Medical, Nursing and Allied Health Students

*1. Today's Date (MM/DD/YYYY):

2. I am applying for this training as

3. I am matriculated full time

*4. Contact Information:(State in name if Ms., Mr., or Dr.)

5. List professional degrees for printed certificate (if applicable):

6. Your current profession: (Select one)

7. How did you hear about the ATTP training?(check all that apply)

8. How would you describe yourself?

9. Are you of Hispanic/Latino origin?

10. Business Information:

11. Are you in a practicum that includes working in an interdisciplinary team?

12. How long have you worked in an interdisciplinary team?

*13. If you have a license in another profession, please provide your license number, profession, and the state in which it was issued. If not, please proceed to #14.

*14. Undergraduate Education

15. Graduate or Medical Education:

16. Professional/Other School or Training:

17. Brief description of your work and/or practicum experience (include any experience with older adults or persons with Parkinson disease and care partners—Max 250 words)

18. Have you worked with diverse racial or cultural groups?

19. Are you currently working in medically underserved areas?

20. Do you have experience with rural populations?

21. Do you have experience in working on an interdisciplinary team?

22. If you are currently on an interdisciplinary team, please answer the questions below:

23. What issues around interdisciplinary teams are of most interest to you?

24. Please select one number that indicates your confidence:

25. What interested you most about this training program? (Max 250 words)

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1. Today's Date (MM/DD/YYYY):

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4. Contact Information:(State in name if Ms., Mr., or Dr.)

*
13. If you have a license in another profession, please provide your license number, profession, and the state in which it was issued. If not, please proceed to #14.

*
14. Undergraduate Education