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Program : HealthQuest at Ithaca College
First Name
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Last Name
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Username
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Primary Email
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Secondary Email
Phone
Date of Birth
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MM slash DD slash YYYY
Address
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City
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State
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Select State
Alabama
Alaska
Arizona
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California
Colorado
Connecticut
DC
Delaware
Florida
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County
Partner Organization
*
Select a PO
Alabama
Alaska
Arizona
Arkansas
Berkshire AHEC
Bronx Westchester AHEC
Brooklyn, Queens and Long Island AHEC
California
Catskill Hudson AHEC
Central New York AHEC
Champlain Valley AHEC
Colorado
Connecticut
DC
Delaware
Erie Niagara AHEC
Florida
Georgia
Hawaii
Hudson Mohawk AHEC
Idaho
Illinois
Indiana
Interior AHEC
Iowa
Kansas
Kentucky
Le Moyne
Louisiana
Maine
Manhattan-Staten Island AHEC
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
NAO
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Country Clinic
North Dakota
Northeast South Dakota AHEC
Northern AHEC
Northern New Hampshire AHEC
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Southern AHEC
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Western New York Rural AHEC
Wisconsin
Wyoming
Zip
*
Gender
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Male
Female
Age
*
Under 20
20-29
30-39
40-49
50-59
60-69
70-120
Unknown
Level of Education
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Select Level of Education
Doctorate
BS
Master
Associate
Elementary/secondary school
Other
No response
Home Address Line 1
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Home City
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Home State
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Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
DC
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Home Zip
Home Zip 4 [Retired]
Home Phone
Home Cell
Are you a Student Or Professional/other?
*
Professional/Other
Student
HRSA ID
*
Job Title
*
Organization
*
Institution Enrolled
*
Service Type
Academia
Ambulatory Practice Site Designated by State Governor
Community-Based Organizations/Non-profit FQHC
Health Care for the Homeless
HHS (US Department of Health and Human Services)
HHS-CDC (Centers for Disease Control and Prevention)
HHS-HIS (Indian Health Service)
HHS-NIH (National Institutes of Health)
HHS-HRSA (Health Resources and Services Administration)
Hospital
HRSA-Area Health Education Center Community-Based Training Site
HRSA-Geriatric Education Center (GEC)
Indian Health/Tribal Health Department
Local Health Department
National Health Service Corp (NHSC) Site
Nursing Home
Public Housing Primary Care
State Health Department
Tribal Government
Veteran's Administration (VA)
Other City Government
Other County Govt
Other Federal Government Other State Government
Other
Anticipated Graduation Date
*
MM slash DD slash YYYY
Notes
*
Academic or Training year
*
Undergraduate-Year 1
Undergraduate-Year 2
Undergraduate-Year 3
Undergraduate-Year 4
Graduate-Year 1
Graduate-Year 2
Graduate-Year 3
Graduate-Year 4
Graduate-Year 5
Graduate-Year 6
Graduate-Year 7
Residency-Year 1
Residency-Year 2
Residency-Year 3
Residency-Year 4
Fellowship-Year 1
Fellowship-Year 21
Department
Work Address Line 1
Work Address City
Work State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
DC
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Work Address Zip
Work Address Zip 4 [Retired]
Work Phone
Work Fax
Ethnicity
*
Select Ethnicity
Hispanic
Non-Hispanic
Black or African American
American Indian/Alaskan Native
Asian
Asian Underrepresented [Retired]
Native Hawaiian/Pacific Islander
White
Other [Retired]
Military Service (Yes /No)
Yes
No
Military Services
Select
Active Duty Military
Reservist
Veteran (Prior Service)
Veteran (Retired)
Individual is not a Veteran
Not Reported
Disadvantaged Background (Yes/No)
Yes
No
Background
Rural Background
Urban Background [Retired]
Suburban Background [Retired]
Frontier Background [Retired]
Unknown Background
Medically Underserved Community (MUC)
Rural Area
Urban Setting [Retired]
Primary Care Setting
None of the Above
Disadvantaged Background
Profession and Discipline for Students
Allied Health
Dentistry
Family Medicine
Gastroenterology
Interdisciplinary
Internal Medicine
Medicine
Mental Health
Nursing
Obstetrics-Gynecology
Occupational Therapy
Pharmacy
Physician Assistant
Public Health
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