The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

6Dqwu5WdsNAWDJv6q3xJBsgNtrBvQTG

Demographics

Please complete the survey below.

Registration profile: The Health Resources and Services Administration (HRSA) provided funding for this training. To demonstrate utilization of the funding, grantees are asked to collect and report participant information that HRSA can aggregate and report for all funded grants. For example, HRSA can report the percentages of participants who have various degrees, or the percentages participating from various professions. Of note, while we are capturing your name, that is not reported to HRSA, instead a unique ID is assigned to every participant for reporting data to HRSA. We do use your name for granting continuing education credits.

Thank you!

This survey will take approximately 15 minutes to complete. All demographic questions are required.
At the end of the survey, you will be provided the registration link for the course.

Attachment:HRSA Required Registration Definitions.pdf

First name

* must provide value

Last Name

* must provide value

Gender

* must provide value

Birth Year

* must provide value

Race/Ethnicity (select what best matches your own identity):

* must provide value

Credentials

* must provide value

License #

* must provide value

License State

* must provide value

This free opportunity is only available to nurses in Iowa, Kansas, Missouri, or Nebraska per HRSA funding. If you are interested in the course, please reach out to con-ionrp@uiowa.edu

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Residing address

* must provide value

Residing City

* must provide value

Residing State

* must provide value

Residing Zip Code

* must provide value

Phone Number (include area code)

* must provide value

Preferred Email

* must provide value

Profession (primary discipline) (type to search)

* must provide value

Employer (please spell out name of employer and do not use abbreviations.)

* must provide value

Employment Status (please select best match)

* must provide value

Highest Degree

* must provide value

Work City

* must provide value

Work State

* must provide value

Employer Zip Code

* must provide value

Is this Employer Rural? 

The HRSA definition of "rural" is a geographical area located in a non-metropolitan county, or an area located in a metropolitan county designated by the Federal Office of Rural Health Policy as rural. Use the Rural Health Grants Eligibility Analyzer to determine whether the Federal Office of Rural Health Policy considers a geographical area rural.

Find more here: https://www.ruralhealthinfo.org/am-i-rural#/

* must provide value

Yes

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Is this employer serving a medically underserved population? 

The HRSA definition of a "medically underserved community" is a geographic location or population of people eligible for designation by the federal government as a Health Professional Shortage Area, Medically Underserved Area, Medically Underserved Population, or Governor's Certified Shortage Area for Rural Health Clinic. Medically underserved populations are federally-designated population groups having a shortage of personal health services, often defined as groups who face economic, cultural, or linguistic barriers to health care, and limited access to services.

Find more here: https://data.hrsa.gov/topics/health-workforce/shortage-areas/by-address

* must provide value

Yes

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Is this Employer a Primary Care Setting?

The HRSA definition of a "primary care setting" means a setting with integrated, accessible health care services by clinicians who are accountable for:, 1) addressing a large majority of personal health care needs, 2) developing a sustained partnership with patients, and 3) practicing in the context of family and community. The following do not meet this criteria: emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, or hospices.

* must provide value

Yes

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Did/do you live in a rural area?

The HRSA definition of "rural" is a geographical area located in a non-metropolitan county, or an area located in a metropolitan county designated by the Federal Office of Rural Health Policy as rural. Use the Rural Health Grants Eligibility Analyzer to determine whether the Federal Office of Rural Health Policy considers a geographical area rural.

Find more here: https://www.ruralhealthinfo.org/am-i-rural#/

* must provide value

Yes

reset

Are you from a disadvantaged background?

The HRSA definition of a "disadvantaged background" means that a person has experienced environmental, economic, or educational disadvantage. These include the following: 1) a person's environment inhibited them from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school, 2) a person's family with an annual income below a level based on low-income thresholds, according to family size established by the US Census Bureau, adjusted annually for the Consumer Price Index, and adjusted by the Secretary of the US Department of Health and Human Services, or 3) a person who comes from a social, cultural, or educational environment that has demonstrably and directly inhibited the person from obtaining the knowledge, skills, and abilities necessary to develop and participate in a health professions education or training program, as long as they are a citizen, national, or lawful permanent resident in the United States, including territories.

* must provide value

Yes

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Are you a veteran?

* must provide value

Today's Date

* must provide value

D-M-Y

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.