UCEDD TRAINEE REGISTRATION FORM

DEMOGRAPHIC INFORMATION

Trainee Name: First Middle Last Birth Date (mm/dd/yyyy) Gender FemaleMale Race WhiteBlack/African AmericanAmerican Indian/ AK NativeAsianNative HawaiianTwo or more racesOtherUnknown Ethnicity HispanicNon HispanicNo Reply Current Address Street City State AlabamaAlaskaAlbertaAmerican SamoaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarshall Islands1MarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundland and LabradorNorth CarolinaNorth DakotaNorthern Mariana IslandsNorthwest TerritoriesNova ScotiaNunavutOhioOklahomaOntarioOregonOtherPalau1PennsylvaniaPrince Edward IslandPuerto RicoQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Zip Permanent Address (same as current) Street City State AlabamaAlaskaAlbertaAmerican SamoaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarshall Islands1MarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundland and LabradorNorth CarolinaNorth DakotaNorthern Mariana IslandsNorthwest TerritoriesNova ScotiaNunavutOhioOklahomaOntarioOregonOtherPalau1PennsylvaniaPrince Edward IslandPuerto RicoQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Zip Primary e-mail Secondary e-mail Primary Phone (###-###-####) What was your positon setting upon admission to this trainee program? For-ProfitGovernment AgencyHospitalHouseholdNon-ProfitNot AppllicableOtherPost-secondary SettingPublic Health/Title VSchool SystemStudentUCEDD/LENDUniversity What was your position title upon admission to trainee program? AdministratorAudiologistNot ApplicableNurseNutritionistOccupational TherapistOtherParentPhysical TherapistPhysicianPsychologistPublic Health WorkerSocial WorkerSpeech-Language PathologistStudentTeacher

ACADEMIC INFORMATION

What is your highest level degree completed? AuDBABSDDSDPTEdDJDMAMDMOTMPHMPTMSMSWNoneOTOtherPhDPsyDPT_ What academic level are you currently enrolled in? DoctoralMastersNon DegreeOtherPost DoctoralUndergraduateNone What degree are you currently working towards? AuDBABSDDSDPTEdDJDMAMDMOTMPHMPTMSMSWNoneOTOtherPhDPsyDPT_

TRAINING PLAN INFORMATION

What is your primary discipline? AudiologyBiological SciencesDentistry/Pediatric DentistryDermatologyDisability StudiesEducation AdministrationEducation: Early Intervention/Early ChildhoodEducation: General Ed.Education: Special Ed - Early Intervention (EEU)Education: Special Ed - EBD (EEU)Education: Special Ed - Severe Profound (EEU)Education: Special EducationEmployment ServicesFamily AdvocateFamily MedicineGenetic CounselingHealth AdministrationHuman Development/Child DevelopmentInterdisciplinaryLawLiberal Arts & Sciences, Humanities, & General StudiesMedicine: GeneralMedicine: PediatricMental and Behavioral Healthmultiple disciplinesNeurologyNursingNutritionOccupational TherapyOrthopedicsOtherPastoralPhysical TherapyPsychiatryPsychologyPublic AdministrationPublic HealthRehabilitation MedicineSocial WorkSpeech-Language Pathology Which CHDD Program will be your primary training program? AutismCIMHGeneticsCTU (LEND)EEUMedical GeneticsOther Who will be your primary supervising faculty? OtherDagmar AmtmannJennifer AnnableSusan AstleyLinda BackenstoseKathryn BarnardForrest BennettDonald BergstromRapheal BernierPeter BeyersFelix BillingsleyTom BirdCathryn BoothAmy BrinCathy BrockAllison BrooksSharan BrownPat BrownDiana CardenasAmy CarlsenMike CarpenterTruman CogginsJulian DaviesBeth Ellen DavisGeraldine DawsonDaniel DohertyAmy DonaldsonAnnette EstesSharon FeuchtRich FolsomTherese GrantMichael GuralnickMark HarniessAnne HarrisAnne HayValerie JohnsKurt JohnsonJean KellyBryan KingKay KoppDahlia KupferCam LanierMercy LaurinoAnne LeavittKathleen LehmanBetty LucasLisa ManclRichard MasseBarb MatlockChris MatsumotoBecky MatterJohn McLaughlinJean MyersRichard NeelHeather OlsonFelice OrlichKate OrvilleJulie OsterlingNancy OyloeDiana PattersonJanine PolifkaSusan RamageDaniel RoyBritta SaltonstallSusan SandallIlene SchwartzDavid ScottRon ScottMilani SmithLaura SnowSusan SpiekerPat SteinburgJoseph StowitschekSally StuartKatherine TeKolsteJohn ThorneCristine TrahmsCeleste TydingioKathie WashingtonKathleen WatsonSara Jane WebbSusan WendelDonna WestonO.R WhiteSamuel Zinner What is your training start date (mm/dd/yyyy)? What is your training end date (mm/dd/yyyy)? Your training type based on training hours is: Short Term (0-39 Hrs) Intermediate (40-300 Hrs) Long Term (> 300 Hrs) My estimated total training hours upon completion are:

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