Section I: Basic Contact Information

FY2018AUCD Directory Paper Form for UCEDD/LEND Users

Section I: Basic Contact Information.

*First Name______

*Last Name______

Degree______

*Phone______

Secondary Phone______

Subscribe to AUCD Digest

*Email______

*User Name______

*Password______

(Username and password must be at least 6 characters long. Letters, numbers, and symbols may be used. Not case sensitive.)

Work Address

*Address line 1______

Address line 2______

*City______

*State______

*Zip/Postal Code______

Section II: Additional Information.

*PositionThe system allows a person to be listed with multiple positions if appropriate. Check all the positions below that apply.Your entry will be validated by the administrator at your site.

Leadership
UCEDD Director / LEND Director
Acting UCEDD Director / Acting LEND Director
Co-UCEDD Director
Associate UCEDD Director / Co-LEND Director
Associate LEND Director
Leadership Administrative Staff:
Primary Activity Coordinators
Adult Services / Pediatric Services
Clinical Services / Person Centered Planning
Community Support / Research
Cultural Diversity / Technical Assistance
Data / Vocational Rehabilitation/Employment
Distance Learning / Training Director
Early Intervention / Community Education Director
Exemplary Services / Medical Director
Information Dissemination / Research Director
Parent/Consumer
Discipline Coordinators
Assistive Technology / Parent/ Family Resources
Audiology / Pediatrics
Dentistry/ PediatricDentistry
Education / Pediatrics: Developmental/ Neonatology
Pharmacy
Epidemiology / Physical Therapy
Family Faculty / Psychiatry
Genetics / Psychiatry: Child
Health Administration / Psychology
Medicine / Psychology: Developmental
Neurology / Public Health
Nursing / Respiratory Therapy
Nutrition / Social Work
Occupational Therapy / Special Education
Speech Language Pathology
Type in position titles for these roles
Specialty Resource Contacts
Project/Program/Clinic Contacts

Section II: Additional Information.

*Position The system allows a person to be listed with multiple positions if appropriate. Check all the positions below that apply. Your entry will be validated by the administrator at your site.

Leadership

FY2018 AUCD Directory Paper Form for LEAH Users 1

UCEDD Director

Co-UCEDD Director

Associate UCEDD Director

Acting UCEDD Director

LEND Director

Co-LEND Director

Associate LEND Director

Acting LEND Director

FY2018 AUCD Directory Paper Form for LEAH Users 1

Primary Activity Coordinators

FY2018 AUCD Directory Paper Form for LEAH Users 1

Adult Services

Clinical Services

Community Support

Cultural Diversity

Data

Distance Learning

Early Intervention

Community Education Director

Exemplary Services

Information Dissemination

Medical Director

Research Director

Parent/Consumer

Pediatric Services

Person Centered Planning

Research

Technical Assistance

Training Director

Vocational Rehabilitation/Employment

FY2018 AUCD Directory Paper Form for LEAH Users 1

Discipline Coordinators

FY2018AUCD Directory Paper Form for PPC Users 1

Assistive Technology

Audiology

Dentistry/ Pediatric Dentistry

Education

Epidemiology

Family Faculty

Genetics

Health Administration

Medicine

Neurology

Nursing

Nutrition

Occupational Therapy

Parent/ Family Resources

Pediatrics

Pediatrics: Developmental/ Neonatology

Pharmacy

Physical Therapy

Psychiatry

Psychiatry: Child

Psychology

Psychology: Developmental

Public Health

Respiratory Therapy

Social Work

Special Education

Speech Language Pathology

FY2018AUCD Directory Paper Form for PPC Users 1

Type in position titles for these roles, if applicable:

Leadership Administrative Staff______

Specialty Resource Contacts______

Project/Program/Clinic Contacts______

*Primary Discipline(Included in DGIS export)______

Discipline(s)Check all that apply.

FY2018AUCD Directory Paper Form for PPC Users 1

Audiology

Biological Study

Dentistry-Pediatric

Dentistry – Other

Disability Studies

Education: Administration

Education: Early Intervention/Early Childhood

Education: General Education

Education/Special Education

Epidemiology

Family Member/Community Member

Family Studies

Family/ Parents/ Youth Advocacy

Genetics/Genetic Counseling

Gerontology

Health Administration

Human Development/Child Development

Interdisciplinary

Law

Liberal Arts & Science, Humanities, and General Studies

Medicine-General

Medicine-Adolescent Medicine

Medicine-Developmental-Behavioral Pediatrics

Medicine-Neurodevelopmental Disabilities

Medicine-Pediatrics

Medicine-Pediatric Pulmonology

Medicine – Other

Mental and Behavioral Health

Nursing

Nursing-General

Nursing-Family/Pediatric Nurse Practitioner

Nursing-Midwife

Nursing – Other

Nutrition

Occupational Therapy

Pastoral

Pharmacy

Person with a disability or special health care need

Physical Therapy

Psychiatry

Psychology

Public Administration

Public Health

Rehabilitation

Respiratory Therapy

Social Work

Speech-Language Pathology

Other - Please specify:______

FY2018AUCD Directory Paper Form for PPC Users 1

AUCD Council Membership: (Check all that apply). Checking/unchecking membership adds/removes member from council listservs.

FY2018AUCD Directory Paper Form for PPC Users 1

Council for Interdisciplinary Service (CIS)

National Community Education Directors’ (NCEDC)

Council on Community Advocacy (COCA)

Multicultural Council (MCC)

National Training Directors’ Council (NTDC Council)

Council on Research and Evaluation (CORE)

No Council Membership (none)

FY2018AUCD Directory Paper Form for PPC Users 1

Professional Areas of Interest and Expertise

Provide a list of “key words,” separated by commas, rather than complete sentences; 200 words or less for each:

Research:______

______

Education:______

______

Service:______

______

Provide an electronic version of:

a brief (roughly 2 pages) vita or bio—plain text is best
a photo (photo should be at most 25(width) x 30(height) pixels with file size no greater than 300KB

Section III: This information WILL NOT be available for public search or display:

*Check if you are a

Former MCHB-program trainee

Former UCEDD trainee

None of the above

*Gender

Male

Female

Year of BIRTH(YYYY): ______

*Year Hired in MCH Leadership Training Program/ Year Hired at Center(YYYY): ______

*Race (select one)

White

Black or African-American

American Indian or Alaska Native

Tribe: ______

Asian (includes Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and other Asian)

Native Hawaiian and Other Pacific Islander (includes Native Hawaiian, Guamanian or Chamorro, Samoan, and other Pacific Islander)

More than One Race

Unrecorded

*Ethnicity (select one)

Hispanic or Latino

Non Hispanic or Latino

Unrecorded

*PRIMARY Employment Role (select one):

Program Director or Associate Director

Senior Faculty: Faculty at the rank of Associate Professor or Professor.

Junior Faculty: Faculty at the rank of Assistant Professor, Lecturer, Adjunct, etc.

Clinical Staff: Individuals with a high degree of expertise and training who specialize in providing clinical services.

Professional Staff: Individuals with a high degree of expertise and training who specialize in performing professional, scientific, or technical activities.

Support Staff: Non-contract employees that include assistants, clerks, coordinators, etc.

Personal relationship with Disabilities(Check all that apply)

Person with a disability

Person with a special health care need

Parent of a person with a disability

Parent of a person with a special health care need

Family member of a person with a disability

Family member of a person with a special health care need

None

Unrecorded

Subscriptions to AUCD Listserves (Check/Uncheck to manage member subscriptions to the following AUCD listserves)

FY2018AUCD Directory Paper Form for UCEDD/LEND Users 1

Aging

AUCD Early Intervention/Early Childhood

AUCD InBrief

Autism

Business Managers

CDC DH Grantees

Disability Studies

Early Intervention/Early Childhood

NSIP

Email Blasts (Funding opportunities, Resources, Announcements)

Emergency Preparedness

Health Care Transition

International

LEND Family

Mental Health and Positive Behavioral Supports

NCBDD RTOIs Grantees

Postsecondary Education

Spirituality and Faith

Trainees

Web Masters

FY2018AUCD Directory Paper Form for UCEDD/LEND Users 1

Section IV: Administrative Fields

Member Affiliation(s)

UCEDD

LEND

*Include this person in EHB upload

Yes

No

*Member status in online Directory

Display

Do not display

Inactive

Pending Submission

Waiting for Approval

Rejected

FY2018AUCD Directory Paper Form for UCEDD/LEND Users 1