2013 Sample CE/PES Participant Registration Form for 2014 HRSA Report

2013 Sample CE/PES Participant Registration Form for 2014 HRSA Report

A-TrACC Field Guide Suggestions

Continuing Education/Professional Education and Support

These forms are intended as an example only, and their use is not required by HRSA.

1Today’s Date: / 2AHEC Center:
3Information for this form is provided voluntarily. AHEC is required to report information about program participants. Data will be kept private to the extent allowed by law and will be referenced periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form. Please type or print clearly.
4Participant Unique ID (AHEC Office Use Only): / 5Participant Type (select one)
Student Healthcare Prof/Worker Other
6Last Name/First name / 7Gender
Male Female / 8Age <20 30-39 50-59
20-29 40-49 60 and over Not Reported
9Address / 10City / 11County (Parish or Borough) / 12State / 13Zip code (9 digit as possible)
14Primary Phone # / 15Permanent Email address
16 Ethnicity (select one)
Hispanic
Non Hispanic / 17Race (select all that apply)
African American / Black
American Indian/Alaskan Native / Asian
Native Hawaiian/Other Pacific Islander
White
18Employer Name
19Work/ Practice Location(s)Address / 20City / 21County (Parish or Borough) / 22State / 23Zip code (9 digit as possible)
24Are you employed by or work in the following? (select all that apply)
Federally-qualified health center (FQHC) – includes Community Health Center, health care for the homeless; primary care public housing, migrant health center, school-based health center, rural health clinic)
Medically Underserved Community
Primary Care Setting
Rural Setting (Non- Metropolitan Statistical Area County)
Other type setting – Please specify ______
25 Health Profession Discipline (Select one and specify below)
Behavioral Health
Please specify ______
Community Health Worker
Dental Assistant
Dental Hygiene
Dentistry
Home Health Aide
Medicine: Primary Care
Please specify ______/ Medicine: Specialist
Please specify ______
Nursing – NP
Please specify ______
Nursing - Other Advanced Practice
Please specify ______
Nursing - Licensed practical/vocational nurse (LPN/LVN)
Nursing - Registered Nurse (RN) / Optometry
Pharmacy
Physician Assistant
Public Health
Please specify ______
Other
Please specify ______
26Do you intend to apply the training from this activity toward employment or professional requirements, continuing education credit, certification, or credentialing? Yes No

Shaded and italicized fields are not required by or reported to HRSA.

1CEP A-TrACC Field Guide 2013 Forms for 2014

2013 Sample CE/PES Evaluation Form for 2014 HRSA ReportA-TrACC Field Guide Suggestions

Continuing Education/Professional Education and Support

These forms are intended as an example only, and their use is not required by HRSA.

1Information for this form is provided voluntarily. AHEC is required to report information about program participants. Data will be kept private to the extent allowed by law and will be referenced periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form. Please type or print clearly.
2Today’s Date: / 3CE Offering Title:
41. In this educational session I increased my knowledge of ______.
Strongly Agree
1____ / Agree
2____ / Neither Agree nor Disagree
3____ / Disagree
4____ / Strongly Disagree
5 ____ / Not Applicable/No response
6 ____
52. After completing this CE I improved skill in ______.
Strongly Agree
1____ / Agree
2____ / Neither Agree nor Disagree
3____ / Disagree
4____ / Strongly Disagree
5 ____ / Not Applicable/No response
6 ____
63. After completing this educational session I intend to improve : ______
74. I will (change in practice statement objective) ______.
Strongly Agree
1____ / Agree
2____ / Neither Agree nor Disagree
3____ / Disagree
4____ / Strongly Disagree
5 ____ / Not Applicable/No response
6 ____
85. Before completing this educational session, I (same change in practice statement from 4 above) ______.
Strongly Agree
1____ / Agree
2____ / Neither Agree nor Disagree
3____ / Disagree
4____ / Strongly Disagree
5 ____ / Not Applicable/No response
6 ____

Shaded and italicized fields are not required by or reported to HRSA.

1CEE A-TrACC Field Guide 2013 Forms for 2014

2013 Sample CE/PES Report Form for 2014 HRSA Report

A-TrACC Field Guide Suggestions

Continuing Education/Professional Education and Support

These forms are intended as an example only, and their use is not required by HRSA

.

AHEC Center: / 1CE Activity Code / 2CE Activity Title
______
3CE Activity Date: / 4Number of offerings
______ / 5Hours of instruction
______ / 6CE Accredited
Yes No
7Is CE Offering location site(s) predominately (check all that apply)
Underserved Non-Underserved Rural (Non-MSA) Non-Rural (MSA)
8Zip code of CE Offering location site(s): ______, ______, ______, ______, ______, (Add others as needed)
9Delivery Mode (select all that apply) Classroom-based Distance learning (online, Webinar) Hybrid
10Primary Topic(select one –
AHEC priority topics are underlined
Health Insurance Marketplaces
Health Reform
Veterans Health
Acute care
Adolescent Health
Advocacy/health policy
African—Americans
Alcohol and substance misuse/prevention
Alternative/complementary medicine
Ambulatory care
American Indian/Alaska Natives
Asian Americans
Asthma
Basic restorative skills
Behavioral assessment and consultation in primary care
Behavioral health
Behavioral interventions for primary care
Bioterrorism/preparedness
Border Health
Cancer
Chronic Disease
Chronic disease management
Clinical Practice Information
Clinical preventive services
Community collaboration
Community health nursing
Community needs assessment
Community—based care
Community—based continuity of care
Computer—based instructions
Consumers' rights
Crisis intervention
Cultural competencies
Data collection and analysis / Delirium
Dementia
Depression
Diabetes
Domestic Violence/Interpersonal violence
Drug—resistant diseases
Elder abuse
E—Learning technology
Emergency preparedness
Emergency training
Environmental health
Epidemiology
Ethics and confidentiality
Ethics/bioethics
Evidence Based Medicine/Practice
Extended care
Financial planning and management (including budgeting)
Focus groups
Food borne Disease
Genetics
Genomics
Geriatrics
Gerontological nursing
Grant writing
Health disparities
Health information technology
Health literacy
Health promotion and disease prevention
Healthy aging
Heart disease
Hepatitis
Hispanics/Latinos
HIV/AIDS
Home health
Homelessness
Hypertension
Infant Health / Infection control
Influenza
Informatics
Information Technology
Injury prevention
Interactive simulated case studies
Interdisciplinary training
Interpersonal skills
Interprofessional education, training and practice
Leadership Training
Leadership/Management
Lesbian, gay, bisexual, transgender individuals
Long—Term Care
Managed Care
Mannequin—based and patient simulators
Maternal and child health
Medical economics
Medication basics
Meeting facilitation
Mental health
Migrant health
Minority health
Native Hawaiian/Pacific Islander
Negotiations
Nursing
Nutrition
Obesity
Oral health
Other
Pain management
Palliative care
Pastoral/Spiritual Care
Patient safety (medical errors)
Perioperative care
Personal care skills
Pharmacology
Physical activity/active lifestyles / Prescription drug abuse
Primary care
Professional development
Youth development
Program design
Program evaluation
Program management
Program planning
Public health infrastructure
Public health law
Public health policy development
Quality improvement and patient safety
Rehabilitation
Research
Rural Health
Secondary care Technology
Sexual health
Sexually transmitted infections
Skills—based training
Social marketing
Stroke
Substance Abuse
Suicide
Survey design
Sustainability
Teledentistry
Telemedicine/telehealth
Tertiary care
Tobacco cessation
Transitional care
Trauma
Tuberculosis
Urban health
Urgent care
Violence
Virtual simulation
Women's health
Workforce development
Wound care
11Secondary Topic (Select one from above and record here. )
12Partners/Consortia used to Offer Training at this site. (Select all that apply)
Academic department—within the institution
Academic department—outside the institution
Educational institution (Grades K—12)
Federal Government —Veterans Affairs
Federal Government—Department of Defense/Military
Federal Government—CDC
Federal Government—SAMHSA
Federal Government—IHS / Federal Government—NIH
Federal Government—AHRQ
Federal Government—FDA
Federal Government—ACL
Federal Government—Other HHS Agency/Office
Federal Government—Other HRSA Program
FQHC or look-alike
Federal Government –Other
Community—based health center (e.g., free clinic)
Health department—Local
Health department—State / Health department—Tribal
Hospital
Nonprofit organization (nonfaith-based)
Nonprofit organization (faith-based)
State Government
Professional Associations
Private/For—profit organization
Local Government
Other
No partners/consortia used
13Interprofessional – Was the CE training interprofessional? ______Yes ______No
14Total # of Participants
______ / 15Gender
____ # Male ____ #Female / 16Age____ #<20 ____ #30-39 ____ #50-59 ____ #=>70
____ #20-29 ____ #40-49 ____ #60 -69 ____ #No Response
17Ethnicity (select one)
____ # Hispanic
____ # Non Hispanic / 18Race (select one) ____ #African American / Black
____ #American Indian/Alaskan Native
____ #Asian / ____ #Native Hawaiian/Other Pacific Islander
____ #White
____ #More than one Race
19Number of Participants by Discipline (NOTE: Greater specificity is required for the Federal Report and can be tabulated from the Participant Registration Form )
____ # Behavioral Health
____ # Community Health Worker
____ #Dental Assistant
____ # Dental Hygiene
____ # Dentistry / ____ # Medicine: Primary Care
____ # Medicine: Specialist
____ # Nursing – NP
____ # Nursing - Other Advanced Practice
____ # Nursing - LPN/LVN
____ # Nursing - RN / ____ # Home Health Aide
____ # Optometry
____ # Pharmacy
____ #Physician Assistant
____ # Public Health
____ # Other
20Are you employed by or work in the following? (select all that apply) Number of participants choosing each category.
__ # *Federally-qualified health center (FQHC)
– includes Community Health Center, health care for the homeless; primary care public housing, migrant health center, school-based health center, rural health clinic)
__ # Medically Underserved Community
__ # Primary Care Setting
__ # Rural Setting
__ # Other Setting
21Number of participantsby disciplineby their zip code address for where they work (or home zip if work not available)
22Participant response to “Do you intend to apply the training from this activity toward employment or professional requirements, continuing education credit, certification, or credentialing?”
______# Yes ______# No
Participants’ Evaluation Responses at the end of the CE Offering
231. In this educational session I increased my knowledge of ______.
Strongly Agree
1____ # / Agree
2____ # / Neither Agree nor Disagree
3____ # / Disagree
4____ # / Strongly Disagree
5 ____ # / Not Applicable/No response
6 ____ #
242. After completing this CE I improved skill in ______.
Strongly Agree
1____ # / Agree
2____ # / Neither Agree nor Disagree
3____ # / Disagree
4____ # / Strongly Disagree
5 ____ # / Not Applicable/No response
6 ____ #
253. After completing this educational session I intend to improve : ______
264. I will ______.
Strongly Agree
1____ # / Agree
2____ # / Neither Agree nor Disagree
3____ # / Disagree
4____ # / Strongly Disagree
5 ____ # / Not Applicable/No response
6 ____ #
275. Before completing this educational session, I ______.
Strongly Agree
1____ # / Agree
2____ # / Neither Agree nor Disagree
3____ # / Disagree
4____ # / Strongly Disagree
5 ____ # / Not Applicable/No response
6 ____ #

Shaded and italisized fields are not required by or reported to HRSA.

1CER A-TrACC Field Guide 2013 Forms for 2014