Please answer all of the following questions:

1. Are you a distance learner for this course? Yes No

2. Are you currently a medical resident? Yes No

3. What type of Institution do you work for? Select one State Health Department/Jurisdiction Local Health Department/Jurisdiction Hospital or Community Health Clinic College or University Law Enforcement/Fire/Emergency Response Community-Based Organization Business or Industry Other (specify)
Specify if Other was selected

4. How long have you worked in this institution/organization? Select one Less than 1 year 1 - 3 years 3 - 5 years 5 - 8 years 8 -12 years 12 - 15 years 15 years or more

5. What underserved area, or organization that targets an underserved area, do you practice in?

Select one Health Department Community Health Center (CHC) Mental Health Center (MHC) Health Care for the Homeless Public Housing Primary Care Rural Health Clinic National Health Service Corp (NHSC) Site Indian Health Service (IHS) or Tribal Health Site Federally Qualified Health Center (FQHC) Health Professions Shortage Area (HPSA) Designated Ambulatory Practice Site Other (specify) Do not practice in an organization that targets an underserved area
Specify if Other was selected

6. What is your profession/occupation? Select one Family Medicine General Internal Medicine General Pediatrics Physician Assistant Nurse Practitioner Nurse Midwife Dentist Primary Care Podiatric Medicine Public Health Physician Preventive Medicine Specialist Public Health Nurse Public Health Dental Worker Health Administrator or Manager Public Health Nutritionist Environmental Scientist or Specialist Health Educator Epidemiologist Biostatistician Public Health Social Worker Mental Health or Substance Abuse Specialist Public Health Planner or Policy Analyst Public Health Law Specialist Community Health Worker Public Health Laboratory Specialist Public Health Veterinarian Emergency Preparedness Specialist Public Health Student Clinical Laboratory Sciences Food and Nutrition Services Health Information Specialist Rehabilitation Technicians and Technologists Advanced Practice Nurse Nursing Student Pharmacist Emergency Management (FEMA, Civil Defense, etc.) First Responder (EMT, Paramedic, Fire, Rescue, Hazmat, etc.) Law Enforcement (Police, State Patrol, FBI, etc.) Support Staff (Administrative Assistant, Clerk, etc.) Teacher/Faculty Other (specify)
Specify if Other was selected

7. What is your gender? Male Female

8. What is your age? Select one Under 20 20 - 29 30 - 39 40 - 49 50 - 59 60 or older

9. Which of the following races/ethnicities to you consider yourself a member of?
Select one American Indian or Alaska Native Asian Black or African American White Hispanic or Latino Native Hawaiian or Pacific Islander More than one race Other (specify)
Specify if other was selected