CLINICAL EXPERIENCE REPORTING FORM (ENTRANCE) CR-1

The Pennsylvania AHEC, in partnership with your school, is seeking to help meet the primary care needs of our communities and to make health careers training a more valuable experience. Results from this survey will be used to support these goals. All survey responses are confidential. Data will only be used within the AHEC program and never for commercial purposes.

Date of Completion: October 18 2017
Your Name


Current Contact Information
Permanent Address
(please list the address of a relative or friend who will know your address after graduation)







Demographics What is the ZIP code of where you lived for most of your high school years?

What is your gender? MALE   |   FEMALE
What is your year of birth?

What ethnicity best desribes you?
Hispanic/Latino   |   Non-Hispanic/Non-Latino

What race best describes you? (select all that apply)
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White

What is your veteran status?
Not a Veteran
Active Duty Military
Reservist
Veteran-Prior Service
Veteran-Retired
Training Program What best describes the educational program in which you are currently enrolled?
Allopathic Medicine
Osteopathic Medicine
Medical Resident
Medical Fellow
Dental School
Dental Assistant
Dental Hygienist
Nursing - LPN
Nursing - RN
Nursing - Nurse Practitioner
Nursing - Nurse Midwife
Nurse Anesthetist
Nursing - MSN (other advanced practice nursing)
Physician Assistant
Pharmacy
Graduate Public Health
Graduate Psychology
Physical Therapy
Occupational Therapist


Do you intend to practice in Pennsylvania? YES   |   NO
Do you intend to practice in a Primary Care Setting? YES   |   NO
Do you intend to practice in a Medically Underserved Area? YES   |   NO
Do you intend to practice in a Rural Area? YES   |   NO
If you can see this, leave the following fields blank


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