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State * Choose... -- AK AL AS AR AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Zip * Enter none for outside of US. Sex * Choose ... Male Female Other Please select the gender you most identify with. Age * Ethnicity * Hispanic or Latino Origin Non-Hispanic or Latino Origin A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Racial Category * Choose... White Black or African American American Indian or Alaska Native Asian Native American or Other Pacific Islander Other If you answered Other to the previous question, please describe. Citizen * Are you a citizen, national, or a lawful permanent resident of the U.S. or the District of Columbia, the Commonwealths of Puerto Rico or the Marianas Islands, the Virgin Islands, Guam, the American Samoa, the Trust Territory of the Pacific Islands, the Republic of Palau, the Republic of the Marshall Islands and the Federated State of Micronesia? Choose... No Yes If yes citizen then… If you answered yes to the previous question, do you come from an environment that has inhibited you from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession? Or do you come from a family with an annual income below a level based on low-income thresholds according to family size published by the U.S. Bureau of Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary, HHS, for use in health professions and nursing programs? Choose... No Yes Rural background * Choose... No Yes Veteran status * Choose... Active Duty Military Reservist Veteran Retired Not a Veteran Veteran Prior Service Primary role * Choose... Clinician Faculty Resident Student Other If you answered Other to the previous question, please describe Profession/discipline * Choose... Behavioral Health – Clinical Social Work Behavioral Health – Other Dentistry – General Dentistry Dentistry – Other Medicine – Family Medicine Medicine – Internal Medicine Medicine – Other Nursing – RN Nursing – APN Nursing – NP – Primary Care Nursing – NP – Geriatrics Nursing – NP – Acute Care Nursing – NP – Family Nursing – Other Occupational Therapy Pharmacy Pharmacy – Other Public Health – Social & Behavioral Sciences Public Health – Other Other If you answered other to the previous question, please describe Date of Birth Professional Degree * Choose... AART APNP ATC BA BS BSN CGC CMA C.N.A. CNS CPhT CST DO DDS DNP DPM DVM EdD EEGT EMT JD LPN MA MB MBA MD MHA MHS MPH MS MSN MSPH MSW ND NP OD OT PA PhD PharmD PT RN RPh RT RVT Other If you answered other to the previous question, please describe Years of experience * Practice Setting Practice Setting * Choose... Clinic Community Hospital Home Care Primary Care (ambulatory) PostAcute/Long-Term Facility (PA/LTC) University or Academic facility Other If you answered other to the previous question, please describe Medically Underserved Community * Choose... No Yes Don't know Indicate whether your practice setting is in a Medically Underserved Community (an umbrella term to describe a geographic location or population of individuals that is eligible for designation by a state and/or federal government as a health professions shortage area; medically underserved area and/or medically underserved population). Practice Setting Geography * Choose... Rural Suburban Urban If requesting continuing education credit in Social Work or Pharmacy, what is your practice license or NABP ID number?