Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

Health Careers Promotion and Preparation (PIPELINE)

Please complete one form for each activity

Total Number of Participants ______

Program Activity: i.e. Summer Program, After School Club, Shadowing

Description of Program: ______

Education Level: Enter Number of Participants in each level

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Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

____K-6

____7-8

____9-12

_____Undergraduate

_____Post Baccalaureate

_____ Displaced Worker

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Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

Race and Ethnicity: Enter number of students in each category

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Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

Latino/Hispanic and

____American Indian/Alaska Native

____Asian

____Black/African American

____Caucasian/White

____Native Hawaiian/Pacific Islander

____Latino/Hispanic and other

Not Latino/Hispanic and

____American Indian/Alaska Native

____Asian

____Black/African American

____Caucasian/White

____Native Hawaiian/Pacific Islander

____Latino/Hispanic and other

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Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

Age: Enter number in each age range

Updated 12/14/16program office bm
Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

____19 + under

____20-30

____30-40

____40-50

____50-60

____over 60

Updated 12/14/16program office bm
Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

Gender: Enter number of each gender

____Male

____Female

Length of Training: Enter number of participants in each length of training category

Updated 12/14/16program office bm
Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

____0-39 hours

____40-60 hours

____61-90 hours

____ 91-120 hours

____120+

____Residency

Updated 12/14/16program office bm
Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period ______Program Date______

Did this program provide information about Public Health Careers? Yes___ No____

Did this program include?

Clinical training? Yes____ No___ (training in a community clinic or health center)

Experiences in health care training (hands on or shadowing)? Yes____ No____

Was clinical or experiential training: (check all that apply)

In a MUC_____ Primary Care Site______Community Based Site _____

Contact with underserved populations_____ (MUC=medically underserved community)

Health Careers Promotion and Preparation (Pipeline)

Post Experience Questionnaire

Thank you for participating in AHEC activities. Please rate the following statements

This activity reinforced my plans to pursue a health professions career.

Strongly Agree Agree Somewhat Agree Disagree Strongly Disagree NA

1 2 3 4 5 6

This activity reinforced my interest to work with vulnerable populations and/or in an underserved community.

Strongly Agree Agree Somewhat Agree Disagree Strongly Disagree NA 1 2 3 4 5 6

(If applicable) This activity reinforced my interest to work in a rural setting.

Strongly Agree Agree Somewhat Agree Disagree Strongly Disagree NA 1 2 3 4 5 6

Health Careers that you are interested in as a result of this activity:

______

Comments about your experience:

______

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