POPHTC Registration Page

1. First Name	Last Name
2. Address City	State Zip
3. Email
4. Gender Male Female
5. Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More Than One Race:
6. Ethnicity Hispanic or LatinoNot Hispanic or Latino
7. Age Group Under 20 years40-49 years 20-29 years50-59 years 30-39 years60 years or older
8. What is the highest level of education you have completed? Doctorate degreeProfessional (incl. JD, MD, DDS, DVM) Master's degreeAssociate degree Bachelor's degreeHigh School Diploma (incl. GED) Other:
9. What academic education in public health have you completed? (please check all that apply) Doctorate degree (e.g., DrPH) Master's degree (e.g., MPH, MSPH) Bachelor's degree (e.g., BSPH) N/A - I do not have an academic degree in public health
10. What is your current, primary discipline?
Primary Care Disciplines Family Medicine General Internal Medicine General Pediatrics Dentistry Primary Care Podiatrics Medicine Physician Assistants Nurse Practitioners Nurse-Midwives	Other Health Professions Allopathic Medicine Osteopathic Medicine Nurse Anesthetist Other Advanced Education Undergraduate Nursing Registered Nurse Chiropractic Dental Public Health Public Health Preventive Medicine Pharmacy Clinical Psychology Health Administration Social Work Veterinarian	Allied Health Disciplines Clinical Laboratory Sciences Food and Nutrition Services Health Information Rehabilitation Technicians and Technologists Dental Assistants Other Disciplines Other:
11. In which underserved area do you primarily practice? Health DepartmentCommunity Health Center Mental Health CenterHealth Care for the Homeless Public Housing Primary CareRural Health Clinics National Health Service CenterIndian Health Center Federally Qualified Health CenterHealth Professional Shortage Area Designated Ambulatory Practice SitesN/A - I do not practice in an organization that intends to reach an underserved area (e.g., universities, American Heart Assn., laboratories) Other:
12. What is your current job title?
13. What is the name of your current organization?
14. Would you like to receive e-mail announcements of training opportunities? Yes No

1. First Name

Last Name

2. Address

City

State

Zip

3. Email

4. Gender

Male
Female

5. Race

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More Than One Race:

6. Ethnicity

Hispanic or LatinoNot Hispanic or Latino

7. Age Group

Under 20 years40-49 years
20-29 years50-59 years
30-39 years60 years or older

8. What is the highest level of education you have completed?

Doctorate degreeProfessional (incl. JD, MD, DDS, DVM)
Master's degreeAssociate degree
Bachelor's degreeHigh School Diploma (incl. GED)
Other:

9. What academic education in public health have you completed? (please check all that apply)

Doctorate degree (e.g., DrPH)
Master's degree (e.g., MPH, MSPH)
Bachelor's degree (e.g., BSPH)
N/A - I do not have an academic degree in public health

10. What is your current, primary discipline?

Primary Care Disciplines

Family Medicine
General Internal Medicine
General Pediatrics
Dentistry
Primary Care Podiatrics Medicine
Physician Assistants
Nurse Practitioners
Nurse-Midwives

Other Health Professions

Allopathic Medicine
Osteopathic Medicine
Nurse Anesthetist
Other Advanced Education
Undergraduate Nursing
Registered Nurse
Chiropractic
Dental Public Health
Public Health
Preventive Medicine
Pharmacy
Clinical Psychology
Health Administration
Social Work
Veterinarian

Allied Health Disciplines

Clinical Laboratory Sciences
Food and Nutrition Services
Health Information
Rehabilitation
Technicians and Technologists
Dental
Assistants

Other Disciplines

Other:

11. In which underserved area do you primarily practice?

Health DepartmentCommunity Health Center
Mental Health CenterHealth Care for the Homeless
Public Housing Primary CareRural Health Clinics
National Health Service CenterIndian Health Center
Federally Qualified Health CenterHealth Professional Shortage Area
Designated Ambulatory Practice SitesN/A - I do not practice in an organization that intends to reach an underserved area (e.g., universities, American Heart Assn., laboratories)
Other:

12. What is your current job title?

13. What is the name of your current organization?

14. Would you like to receive e-mail announcements of training opportunities?

Yes
No