|
Upon submitting this participant profile form, you
will receive an email confirming your FCPHP USER ID (which is the same
as your email address).
THIS DOES NOT REGISTER YOU FOR ANY FCPHP COURSES.
Fields Marked * below are required.
This information will appear exactly as it is entered and will be used to
create your course certificates of completion, and participant rosters. Please
do not use all capital letters when completing this form. Thank you.
|
| Email Address (USER ID)*: |
**Please make sure your email is typed correctly. This will
be your USER ID**
We request that all Florida Department of Health employees
use their FDOH email address Example:james_smith@doh.state.fl.us |
| Password*: |
|
| Confirm Password*: |
|
| First Name*: |
|
| Last Name*: |
|
| Position Title*: |
|
| Employer*: |
Examples: Name of County Health Department or Name of FDOH central office
|
| Mailing Address*: |
|
| City*: |
|
| Country*: |
|
| State/Territory*: |
|
| County*: |
|
| Zip Code*: |
|
Daytime Phone*:
|
Example: xxx-xxx-xxxx |
| Extension: |
|
| Fax: |
|
| Professional License: |
|
|
The funding agency for the FCPHP requests that we report summary demographic
data on participants who attend our training programs. We ask that you please provide
the following information, but it is voluntary. This information will only be
reported in summary form. Individuals will not be identified.
|
Job Position:
(Select only one) |
Primary Care
Dentist
Physician
Psychiatrist
Other Health
Clinical Laboratory Technician (e.g., Phlebotomists,Histologic Technician)
Dental Worker (e.g., hygienist,assistant)
Home Health Aide/Medical Assistant
Nurse/Nurse Practitioner/Physician Assistant
Nutritionist/Dietician
Pharmacist
Public Health Laboratory Specialist
Public Health/Health Sciences Student
Therapist (e.g. Physical, Occupational, Respiratory, Speech)
Veterinarian
Public Health Professions
Biostatistician
Bioterrorism Coordinator
Community Outreach/Field Worker
Environmental Engineer (include technician)
Epidemiologist
Health Administrator
Health Educator or Trainer
Health Information Systems/Data Analyst
Hospital Administrator/Management
Health Planner/Researcher/Analyst
Infection Control/Disease Investigator
Other Public Health Technician
Mental and Behavioral Health
Mental Health/Substance Abuse Clinician
Mental Health/Substance Abuse Counselor
Psychologist
Social Worker
Other
Elected government official
Emergency Management (FEMA.Cival defence, etc.)
First Responder (EMT,Paramedic,fire,rescue,Haz Mat., etc.)
Law/judicial/attorney
Law Enforcement (Police, state patrol, FBI,etc.)
Support staff (administrative assistant, clerk, etc.)
Public Information Staff (media spokesperson, public relations staff, media liason)
Teacher/Faculty
Other
|
| Type of Organization: |
State Health Department/Jurisdication
Local Health Department/Jurisdication
Hospital or Community Health Clinic
College or University
Law enforcement/fire/emergency response
Community based organization
Business
Others
|
|
The contact information you have provided may be shared with Florida Department
of Health officials upon the Department’s request.
THIS DOES NOT REGISTER YOU FOR FCPHP COURSES.
It provides access to sign up for the course(s) you plan to attend. |
