UTMB Evidence Collection
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Registration
Please complete the confidential user information below. We guarantee that your name and personal information will never be shared with any third parties without your consent. For more information, please read the UTMB Privacy Policy.

Required fields are marked in bold.

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User Information
First Name:
MI:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Country:
E-mail:
Phone:
Credentials: LVN
RN
NP
CNS
CNM
CRNA
Other
RN License #
Education:
Specialty:
Other:
Institution:
Department:

Demographic Information
1. Your county of residence:
   
2. What is your gender?  

   
3. What is your age?  





 
4. To which of these races/ethnicities do you consider yourself a member?
American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
More than One Race
Other
 
5. Please indicate what type of institution you work for:
Long Term Care/Nursing home
Trauma Center Level I, II, or III
Home Health Agency
Community Hospital
Law Enforcement/Fire/Emergency Response
Community-Based Organization
College or University
Ambulatory acute care clinic
Other
 
6. Please indicate what underserved area or organization that targets an underserved area, if any, you practice in.
Health Department
Community Health Center
Migrant Health Center
Health Care for the Homeless
Public Housing Primary Care
Rural Health Clinics
National Health Service Center
Indian Health Center
Federally Qualified Health Center
Health Professions Shortage Area
Designated Ambulatory Practice Sites
Other
Not associated