CT Health Education Center
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CT Health Education Center
YHSC-TIF end usage date-July 24-2023
Log Hours
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Program Name:
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YHSC
CHSC
CBET (List program name below)
CBET Program Name:
First Name:
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Last Name:
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Gender (select one):
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Female
Male
Non-binary
A gender not listed (please provide in the field below):
Prefer not to say
Gender not listed above:
Birthdates:
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Format: 10/31/2024
Street Address:
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City/Town:
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State:
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Zip Code:
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Primary Phone #:
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Current University Email Address:
Racial background (select all that apply):
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Some other not listed (please provide in the next field):
Prefer not to say
Race not listed above:
Ethnicity:
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Hispanic/Latino
Non-Hispanic/Non-Latino
Are you a veteran?:
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Yes, Active Duty Military
Yes, Reservist
Yes, Veteran (prior service)
Yes, Veteran (retired)
No
Can you answer yes to any of the following?:
1. You are (or will be) the first generation in your family to attend college ____ 2. You have or currently receive Scholarship or Loan for Disadvantaged Students____ 3. While growing up, did you or your family ever use federal or state assistance programs? (E.g., free or reduced-price school meals, subsidized housing, Supplemental Nutrition Assistance Program [SNAP], Medicaid, etc.) ____ 4. While growing up, did you live where there were few medical providers at a convenient distance?
Yes
No
In which kind of community did you grow up?:
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Urban
Suburban
Rural
Emergency Contact Name:
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Emergency Contact Relationship:
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Emergency contact Phone:
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In what institution or health career program are you currently enrolled?:
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ADMIN ACCOUNT
East Lyme High School
Fitch High School
Griswold High School
Kelly STEAM Magnet Middle School
Mashantucket Pequot Tribal Nation (High Five)
New London High School
Norwich Free Academy
Norwich Tech
Old Lyme High School
Tourtelotte High School
Windham High School
Windham Tech
Eastern Connecticut State University
UCONN
Health Education Center (MIP Students)
Three Rivers Community College (Nursing Students)
Other (enter name in the next field)
Other institution or health career program name:
Anticipated Date of Graduation/Completion:
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ADMIN ACCOUNT
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Please select your enrollment year/status::
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ADMIN ACCOUNT
High School Year 1
High School Year 2
High School Year 3
High School Year 4
Undergraduate Year 1
Undergraduate Year 2
Undergraduate Year 3
Undergraduate Year 4
Undergraduate Year 5
Graduate Year 1
Graduate Year 2
Graduate Year 3
Graduate Year 4
Graduate Year 5
Certificate
Other (explain below)
Other enrollment year/status not listed above::
Questions from this point on should be fill out by CBET participants only:
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Please select the health profession program in which you are enrolled::
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Community Health Worker
Dental School
Medical Interpreter
Medical School
Nursing – Certified Nursing Assistant
Nursing – Graduate/CNS/NP – Specify specialty - specify below
Nursing – Registered nurse (RN)
Occupational Therapy
Pharmacy
Physical Therapy
Physician Assistant
Public Health, Graduate
Respiratory Therapy
Social Work
Other - specify below
Nursing specialty or other:
I intend/plan/would like to work in a primary care setting (i.e., Family Medicine, General Internal Medicine, General Pediatrics, OB/GYN, General Dentistry, Community Pharmacy).:
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Yes
No
Undecided
Not Applicable
I intend/plan/would like to work with people who are medically underserved (people who face economic, cultural or linguistic barriers to healthcare).:
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Yes
No
Undecided
Not Applicable
I intend/plan/would like to work in rural areas.:
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Yes
No
Undecided
Not Applicable
Account Creation Date:
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Format: 10/31/2024
Authorization and consent: I certify that the information provided is accurate. The CT AHEC Network, UConn, UConn Health and its agents are given my permission to reproduce for publications, presentations, and internet use any photos taken at program functions. If I choose to withdraw my permission, I must provide written notification. Enter your name and Today's Date:
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