Breadcrumb Home [TEST] landing 2 You must have JavaScript enabled to use this form. Select which one best describes you: Student Resident Fellow Faculty Practitioner/Provider Caregiver Gender: Female Male Nonbinary Transgender Prefer not to respond Age: 19 and under 20-29 30-39 40-49 50-59 60 and over Race/Ethnicity (Select ALL that apply): American Indian or Alaska Native Asian Black or African American Hispanic or Latine Middle Eastern or North African Native Hawaiian or Pacific Islander White Prefer not to respond Would you describe yourself as being from an economically or educationally disadvantaged background? Yes No Did you grow up in or do you currently live in a rural area? Yes No Do you work or train in a rural setting? Yes No Do you work or train in a medically underserved community? Yes No Do you work or train in a primary care setting? Yes No Select where you work or train: Academic Institution Assisted Living Community Hospital Hospice Nursing Home Veterans Affairs Hospital or Clinic Rural Health Clinic Other Please select which profession best describes you: Behavioral Health (social work, counseling, spiritual care, etc.) Dentistry (dental assistant/hygiene, dentist, etc.) Medicine (MD, DO, PA) Nursing (CNA, RN/BSN, NP, etc.) Public Health (epidemiology, health policy, etc.) Other (pharmacy, physical therapy, allied health, etc.) Which Behavioral Health discipline best describes you? Clinical Mental Health Counseling Clinical Psychology Clinical Social Work Counseling Psychology Pastoral/Spiritual Care Substance Abuse/Addictions Counseling Which Dentistry discipline best describes you? Dental Assistant Dental Hygiene General Dentistry Dental Student Which Medicine discipline best describes you? Emergency Family Geriatric Psychiatry Geriatrics Internal Physician Assistant Psychiatry Medical Student Which Nursing discipline best describes you? CNA CNS Home Health Aide LPN/LVN NP-Adult NP-Geropsychiatric Nurse Administrator Nurse Educator Patient Care Associate Public Health Nurse RN/BSN Nursing Student Which Public Health discipline best describes you? Disease Prevention & Health Promotion Epidemiology Health Administration Health Policy & Management Which discipline best describes you? Community Health Worker Dietitian/Nutritionist Direct Service Worker EMT/Paramedic Facility Administrator Occupational Therapy Pharmacy Physical Therapy Speech Therapy Profession Not Listed Leave this field blank Testing - success