University of Minnesota Center for Public Health Preparedness
Centers for Public Health Education and Outreach
http://cpheo.sph.umn.edu/umncphp
612-626-4515

Emergency Preparedness and Response for Environmental Health Professionals

Participant Data Form - University of Minnesota Center for Public Health Preparedness

Please complete this optional attendee information form for our records.
Only aggregate data are reported; no individual identifiers are used for reporting purposes.

Please complete this form the first time you access the course.
If you have previously completed the form for one of the following lessons, please select the appropriate link below.

1. Please select what state you are from

2. If you are from Minnesota, please select what county you are from

3. Learners taking this course come from a variety of backgrounds. The following is a partial list. Please select the category that best reflects your training and background OR select OTHER and describe.

Dentist Health Administrator
Physician Health Planner/Researcher/Analyst
Psychiatrist Infection Control/Disease Investigator
Clinical Laboratory Technician
      (e.g. Phlebotomists, Histologic Technician)		 Mental Health/Substance Abuse Clinician
      or Counselor
Dental Worker (e.g., Hygienist, Assistant) Psychologist
Home Health Aide/Medical Assistant Social Worker
Laboratory Professional Teacher/Faculty
Nurse (include all RN, LPN) Emergency Management (FEMA, Civil defense, etc.)
Nurse Practitioner/
      Physician Assistant		 First Responder
      (EMT, Paramedic, Fire, Rescue, Haz Mat, etc.)
Pharmacist Law/judicial/attorney
Pharmacy Technician Law Enforcement (Police, State patrol, FBI, etc.)
Therapist
      (e.g. Physical, Occupational, Respiratory, Speech)		 Support Staff
      (Administrative assistant, Clerk, etc.)
Veterinarian
Biostatistician		 Public Information Staff
      (Media spokesperson, Public relations staff, Media liaison
Environmental Engineer, Scientist or Specialist Student (Please select)
Epidemiologist OTHER (Please describe)
Health Educator or Trainer
   

3a. If different from the background and training you designated above, please specify your current role:

4. For which type of organization do you work?

State health department/jurisdiction
Local public health department/jurisdiction
Hospital or community health clinic
College or University
Law enforcement/ fire/ emergency response
Community-based organization
Business
Elementary or High School
Retired
Self-employed
Volunteer
OTHER (Please describe)

5. Demographic Information

Race

Black or African American Native Hawaiian or Pacific Islander
Alaska Native Hispanic or Latino
American Indian White
Asian OTHER

Gender

Male Female

Thank you for taking the time to fill out the information.