* 1. NAME

* 2. JOB TITLE

* 3. ORGANIZATION OR AGENCY NAME

* 4. ORGANIZATION OR AGENCY ADDRESS

* 5. TELEPHONE NUMBER

* 6. EMAIL ADDRESS

* 7. YOUR EDUCATION AND TRAINING

Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training. Begin with your most recent degree.

PLEASE PROVIDE THE FOLLOWING: institute and location, degrees awarded (if applicable), year(s) (e.g. 2001-2004), and field of study.

For example: UNMC, Omaha, NE; MPH; 2010-2012; Epidemiology

* 8. CONTINUING EDUCATION

Briefly describe any continuing education / training you have had in the past three years related to epidemiology, statistics, needs assessment or program evaluation.

PLEASE PROVIDE THE FOLLOWING: sponsoring agency and title of workshop/course, length of training (hours or days), and topics covered.

* 9. How many years following the award of your last degree have you been employed in conducting epidemiologic research, statistical analysis, and/or program evaluation?

* 10. Please briefly describe your CURRENT job responsibilities.

* 11. How many years have you been performing your current job responsibilities?

* 12. Please briefly describe key research or program evaluation project(s) that you have directly completed in the past THREE years.

* 13. How would you describe your skills in carrying out the following activities?

  NO EXPERIENCE? No experience BASIC? Some experiences, though not proficient; need guidance INTERMEDIATE? Some experience and fairly proficient; can work independently ADVANCED? Experienced and proficient; can take the lead and supervise others
Conducting MCH needs assessment and priority setting
Designing and implementing evaluations of MCH programs and policies
Monitoring performance on MCH indicators
Using SAS, SPSS, STATA, or any other statistical package
Cleaning and organizing data, creating and recoding variables, and conducting basic analysis (frequencies, crosstabs)
Using basic multivariable regression methods (e.g. linear, logistic)
Using specialized multivariable regression methods (e.g. generalized linear models, propensity scoring)
Interpreting multivariable regression results
Conducting Perinatal Periods of Risk (PPOR) analysis
Quality improvement analysis and reporting
Creating tabular and graphic summaries of data findings
Data translation and communication

* 14. What datasets do you use directly to conduct epidemiologic research, statistical analysis, and/or program evaluation (e.g. Census data, vital records, NSCH, NS-CSHCN, WIC, PRAMS, YRBS, etc.)?

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