UCEDD TRAINEE REGISTRATION FORM

DEMOGRAPHIC INFORMATION

Trainee Name: First Middle Last Birth Date (mm/dd/yyyy) Gender FemaleMaleNon-binary - third genderPrefer to self-describePrefer not to sayTransgenderCisgenderAgenderGenderqueerA gender not listed Race WhiteBlack/African AmericanAmerican Indian/ AK NativeAsianNative Hawaiian or Other Pacific IslanderTwo or more racesOtherUnknownPrefer to self-describePrefer not to saySome other race, ethnicity, or origin Ethnicity No, not of Hispanic, Latino/a/x, or Spanish originYes, Mexican, Mexican American, Chicano/a/xYes, Puerto RicanYes, CubanYes, Another Hispanic, Latino/a/xSome other race, ethnicity, or originPrefer to self-describePrefer not to say 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-ProfitOtherPost-secondary SettingPublic Health/Title VSchools or School SystemStudentUCEDD/LEND What was your position title upon admission to trainee program? AdministratorAudiologistNot ApplicableNurseNutritionistOccupational TherapistOtherParentPhysical TherapistPhysicianPsychologistPublic Health WorkerSocial WorkerSpeech-Language PathologistStudentTeacher Personal Relationship with Disabilities is the trainee a (check all that apply): Person with a disability Person with a special health care need Parent of a person with a disability Parent of a person with a special health care need Family member of a person with a disability Family member of a person with a special health care need

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 SciencesChild LifeDentistry/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-Developmental-Behavioral PediatricsMedicine: GeneralMedicine: PediatricMental and Behavioral HealthMultiple disciplinesNeurologyNursingNutritionOccupational TherapyOrthopedicsOtherPastoralPhysical TherapyPsychiatryPsychologyPublic AdministrationPublic HealthRehabilitation MedicineSelf AdvocateSocial WorkSpeech-Language Pathology Which CHDD Program will be your primary training program? AutismCIMHGeneticsCTU (LEND)EEUMedical GeneticsOther Who will be your primary supervising faculty? OtherSusan AdelmanDagmar AmtmannSusan AstleyKathryn BarnardDonald BergstromRapheal BernierPeter BeyersFelix BillingsleyTom BirdCathryn Booth-LaForceAmy BrinAllison BrooksSharan BrownPat BrownKatie BuckMara CalhounDiana CardenasAmy CarlsenMike CarpenterJulian DaviesGeraldine DawsonJessica DeBordDaniel DohertyAmy DonaldsonAshland DoomesAnnette EstesSharon FeuchtBrooke FittererBeth GendlerJennifer GerdtsMegan GoldenshteynTherese GrantMichael GuralnickMark HarnissAnne HarrisSarah HarshAnne HayValerie JohnsKurt JohnsonJean KellyBryan KingKay KoppSonja KottkeMercy LaurinoAnne LeavittKathleen LehmanSue LivingstoneSophie LuLisa ManclJennifer ManheimRichard MasseBarb MatlockChris MatsumotoBecky MatterMari MazonBob MillerEmily MeyersRichard NeelBeth OgataHeather OlsonJennie OlsonFelice OrlichKate OrvilleJulie OsterlingDiana PattersonCara PiersonJanine PolifkaSusan RamageDaniel RoyMollie RoyerBritta SaltonstallSusan SandallIlene SchwartzRon ScottIvanova SmithLaura SnowSusan SpiekerPat SteinburgJoseph StowitschekSally StuartJohn ThorneCeleste TydingioSara Jane WebbSusan WendelDonna WestonO.R WhiteEmily WilliamsSamuel 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 (40-149 Hrs) Intermediate (150-299 Hrs) Long Term (> 300 Hrs)

Comments:

Complete the CAPTCHA Verification to Submit

If you have problems with this form, contact Richard Masse.
Click here for paper registration form.