Choose Username & Password Username * Password * Confirm Password * More Details Email Address * First Name * Last Name * Address * City * Country * Select a country Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State Of Bonaire, Sint Eustatius And Saba Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic Of Iraq Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State Of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension And Tristan Da Cunha Saint Kitts And Nevis Saint Lucia Saint Martin (French Part) Saint Pierre And Miquelon Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch Part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And The South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Timor-Leste Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic Of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe Demographics We are collecting the following demographic data to comply with our HRSA-funder reporting requirements. 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?