Small Group Provider Lupus Education UHC

AHEC CE Participant Registration Form

Information for this form is provided voluntarily. AHEC is required to report information about program participants. Data will be kept private to the extent allowed by law and will be referenced periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form. Please type or print clearly.

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* 1. Participant's Name

First Name

Last Name

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* 2. Participant Type (select one)

Healthcare Professional/Worker

Student

Retired/Unemployed

Other

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* 3. Employer Name

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* 4. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 5. Primary Phone #

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* 6. Permanent Email address

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* 7. Number of years/mos. worked at this site yrs mos.

Years

Months

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* 8. Do you currently serve as a preceptor for students?

Yes

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* 9. Name of health professions school attended, if applicable:

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* 10. Year of Graduation

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* 11. As a student, did you participate in a rural or community rotation?

Yes

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* 12. Are you employed by or work in the following? (select all that apply)

Community Health Center (CHC) (Federally Designated), or Federally Qualified Health Center (FQHC)

Primary care worksite

Rural Setting

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* 13. Health Profession / Worker Discipline

Community Health Care Worker

Dental Assistants

Dental Hygienists

Dentists

Dietitians/ Nutritionists

First Responders (EMT, Paramedic, Fire Rescue, HazMat)

Health Services/Hospital Administration

Home Health Aide

Nurses (Licensed/Practical)

Nurse (Registered)

Nurse Midwives

Clinical Nurse Specialist, (specialty)

Nurse Practitioner-Family

Nurse Practitioner-Other

Occupational Therapists

Optometrists

Pharmacist

Physical Therapists

Physician, Family Medicine

Physician, Internal Medicine

Physician, Pediatrics

Physician, OB/GYN

Physicians, Other

Physician Assistant

Psychologist, Clinical

Public Health- Disease Prevention & Health Promotion

Public Health- Environmental Health

Public Health-Epidemiology

Public Health –Health policy & Management

Public Health Infectious disease control

Public Health Injury prevention

Public Health Social & Behavioral Sciences

Social Workers, Clinical

Social Work, Other

Substance Abuse/addictions

Counseling

Other: List any specialties not listed:

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* 14. Do you plan to apply this training toward your employment requirements, continuing education credit, certification, or credentialing?

Yes

N/A

Small Group Provider Lupus Education UHC

AHEC CE Participant Registration Form

Question Title

* 1. Participant's Name

Question Title

* 2. Participant Type (select one)

Question Title

* 3. Employer Name

Question Title

* 4. Address

Question Title

* 5. Primary Phone #

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* 6. Permanent Email address

Question Title

* 7. Number of years/mos. worked at this site ____ yrs ____mos.

Question Title

* 8. Do you currently serve as a preceptor for students?

Question Title

* 9. Name of health professions school attended, if applicable:

Question Title

* 10. Year of Graduation

Question Title

* 11. As a student, did you participate in a rural or community rotation?

Question Title

* 12. Are you employed by or work in the following? (select all that apply)

Question Title

* 13. Health Profession / Worker Discipline

Question Title

* 14. Do you plan to apply this training toward your employment requirements, continuing education credit, certification, or credentialing?

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* 15. Please provide any specific dietary restrictions or requests in the space below.

* 7. Number of years/mos. worked at this site yrs mos.