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2011
June
S
Student Profile (Contact Info)
Student Profile (Contact Info)
Student Profile (Contact Info)
0%
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Hello:
The THR University clinical education department maintains a database containing student contact information for faculty that is also used to track immunization and CPR requirements. You have been asked to submit your profile information via this online tool in order to populate the database more efficiently. The electronic form consists of 21 items and will take you approximately 10 minutes to complete.
Your information will remain
strictly confidential
. If you have questions at any time about the survey or the procedures, you may contact Jerry Stern at 682-236-6199 or by email at
[email protected]
.
Thank you very much for your time and support. Please start completing the form now by clicking on the Continue button below.
*
Semester:
-- Select --
1
2
3
4
*
Last Name:
*
First Name:
*
Street:
Apartment No.:
*
City:
*
State:
-- Select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
*
Zip Code:
Home Phone:
Cell Phone:
Work Phone:
*
Last 4 digits of SSN#:
*
E-mail address (Please use THR e-mail address if a THR employee):
*
Where do you currently work?
THR
Not currently working
Other
Please select the entity in which you currently work.
-- Select --
Texas Health Arlington Memorial Hospital
Texas Health Harris Methodist Azle
Texas Health Harris Methodist Hospital Cleburne
Texas Health Harris Methodist Hospital Fort Worth
Texas Health Harris Methodist Foundation
Texas Health Harris Methodist Hospital Hurst-Euless-Bedford
Texas Health Harris Methodist Hospital Southwest
Texas Health Harris Methodist Hospital Stephenville
Texas Health Presbyterian Foundation
Texas Health Presbyterian Allen
Texas Health Presbyterian Dallas
Texas Health Presbyterian Denton
Texas Health Presbyterian Kaufman
Texas Health Presbyterian Plano
Texas Health Research & Education Institute
Texas Health Resources
Texas Health Springwood Allen
Texas Health Springwood Arlington
Texas Health Specialty Hospital Fort Worth
Texas Health Springwood Southlake
THR Employment Status
Full time
Part time
PRN
THR Employee ID#:
Number of years at current employer. (Please enter the number of years, i.e., "3"
not
"three".)
*
School
El Centro
TCU
UTA
Other
*
Program
ADN
APBSN
CNL
Other
Student ID
*
Name:
*
Contact Phone Number:
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