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Personal Details

Complete this field if you wish to receive Continuing Education credit
Explain Other:
What was your relationship to this person?
What was your relationship to this person?


Please select all the options below that describe why you are taking these modules:

What school do you attend?
Who is your employer?
Explain Other:

Student Demographics

Rural – a geographical area located in a non-metropolitan county, or an area located in a metropolitan county designated by the Federal Office of Rural Health Policy as being considered rural.

Disadvantaged background – a citizen, national, or a lawful permanent resident of the United States, the Commonwealths of Puerto Rico or the Marianas Islands, the U.S. Virgin Islands, Guam, American Samoa, the Trust Territory of the Pacific Islands, the Republic of Palau, the Republic of the Marshall Islands, or the Federated State of Micronesia who is:
Refers to an individual’s environment inhibited him/her from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school.
Refers to an individual from a family with an annual income below a level based on low-income thresholds, according to family size established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of the U.S. Department of Health and Human Services, for use in all health professions programs. A family is a group of two or more individuals. The Secretary updates these income levels in the Federal Register annually.
Refers to an individual who comes from a social, cultural, or educational environment that has demonstrably and directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a health professions education or training program.

Veteran – any person who served in one of the uniformed services of the United States. The uniformed services include: The Army, Navy, Air Force, Space Force, Marines, Coast Guard, Public Health Service, and National Oceanic & Atmospheric Administration Commissioned Officers Corps.

Please provide a valid email address if we may contact you in the future with follow-up questions regarding your career choices, thank you!

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