North East Pennsylvania Area Health Education Center

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, Maiden)

Please provide your current contact information:

Cell Phone Number

Current Email Address (Required for online submission)

What is your permanent address:
(please list the address of a relative or friend who will know your address after graduation)

What is your permanent address?
(Name, Relationship, Street Address, City, State, Zip)

Permanent Email Address (after graduation)

Permanent Phone Number

DEMOGRAPHICS

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

What is your gender?

What is the year of your birth?

Your ethnicity?

Your race? (Check all that apply.)





Your veteran status?

What is the name of your current school?
(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)

Do you intend to practice in Pennsylvania?
Do you intend to practice in a Primary Care Setting?
Do you intend to practice in a Medically Underserved Area?
Do you intend to practice in a Rural Area?

Enter the below form code (all numbers)

Eastcentral - Northeast Pennsylvania Area Health Education Center
5662 Interchange Road Lehighton, PA 18235 | Phone: 610.379.2001 | Fax: 610.379.2005 | ecneahec.org