NEPA-AHEC - Student Experiences

Enhancing access to health care through education

Clinical Experience Reporting Form (Entrance) CR - 1
for NEPA-AHEC

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 Completed (Month/Day/Year)

Your name? (Last, First, Middle)

What is the year of your birth?

What is the zip code of where you lived most of your high school years?

What is your gender?

Your race/ethnicity? (Check all that apply.)

Other:

What is your current address? (Street Address, City, State, Zip)

What is your permanent address? (You may list the address of a relative or friend who will know your address after graduation.) (Name, Relationship, Street Address, City, State, Zip)

Your preferred email address? (Required for online submission)

What is the name of your current school and program?
(Name of School, Name of Program, Street Address, City, State, Zip)

What best describes the educational program in which you are currently enrolled?

Other

What year of your program are you currently in? (1,2,3,4, other-please specify)

Please indicate the extent to which you agree with the following statements. (Please answer all.)
In Pennsylvania
In a rural area
In an urban area
In a medically underserved area