ࡱ > v y u } # bjbj 4t h h h ] 8 = G G ( o o @ @ @ = = = = = = = ? B l = @ " @ @ @ = o G = @ j V o = @ = 9 - ; o h 7 : = = 0 = : 8 B B 0 ; B ; @ @ @ @ @ @ @ = = @ @ @ = @ @ @ @ B @ @ @ @ @ @ @ @ @ : NIRS Trainee Form FY09 For use by LEAHs, PPCs, and DBPs *Response Required MAIN RECORD ID Number: __________________ * First Name ____________________________ MI_____ *Last Name___________________________________ Former Name: _________________________ *Academic Degree/Credential Achieved:__________________________________________ *Current Address: _________________________________________________________________________ County of Origin:____________________________________ ( out of state ( unknown (Because students often move to a location near the school they will be attending, we strongly recommend asking trainees to provide the name of the county they relocated from to attend school, rather than their current county of residence.) Email Address: ______________________________ Phone: ( _____ ) ______ - __________ Name of Permanent Contact: __________________________________________________________________ Relationship of Permanent Contact: ___________________________________________________________ Permanent Address: __________________________________________________________________________ Permanent Phone: ( _____ ) ______ - ________ Date of Birth: ___ /___ /_______ *Gender: M F * Race (check one): White refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American refers to people having origins in any of the Black racial groups of Africa. American Indian and Alaskan Native refer to people having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.Tribe:___________________ Asian refers to people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent (e.g. Asian Indian). Native Hawaiian and Other Pacific Islander refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Two or more races includes individuals who identify with two or more racial designations. Other is included for individuals who are unable to identify with the categories. *Ethnicity (check one): Hispanic is an ethnic category for people whose origins are in the Spanish-speaking countries of Latin America or who identify with a Spanish-speaking culture. Individuals who are Hispanic may be of any race. Hispanic Non Hispanic *Position Setting at Admission: Student Schools or School System (includes early intervention programs, elementary and secondary) Post-secondary (Academic) Setting UCEDD/LEND Government Agency For-Profit Non-Profit Public Health/Title V Hospital Private Practice Other *Position Title at Admission: _________________________________________________ Personal relationship with Disabilities: Is the trainee a (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 TRAINEE YEAR RECORD *Fiscal Year: 2009 Academic Level (Current enrollment Degree Program (provide appropriate abbreviation, e.g., BA, status, not highest degree earned) MA, PhD, DDS, etc.) Non Degree Undergraduate ______________________________ Masters ______________________________ Doctoral ______________________________ Post Doctoral ______________________________ Other ______________________________ Position in Program (fellow, resident, intern, grad student, etc):______________________________________ *Discipline: (Check one) ( Audiology( Medicine: General ( Biological Sciences( Medicine: Pediatric( Dentistry/Pediatric Dentistry( Mental and Behavioral Health( Disability Studies( Nursing( Education: Administration( Nutrition ( Education: EI/Childhood( Occupational Therapy ( Education: General Education( Pastoral ( Education: Special Education( Physical Therapy( Family Advocate( Psychiatry( Genetic Counseling( Psychology( Health Administration( Public Administration( Human Development/Child Development( Public Health( Interdisciplinary( Rehabilitation( Liberal Arts & Sciences, Humanities, & General Studies( Social Work( Law( Speech-Language Pathology ( Other Please specify: *Current Contact Hours: (for current reporting period only--Must be 9 or more) _______ *Enrollment Status: (Check one) ( Full-Time Student ( Part-Time Student *Year Start Date: _____ / _____ / _____ (Pertains to training program only, not academic program) *Year Completion Date: _____ / _____ / ______ (Pertains to training program only; if the completion date for this year is currently unknown, supply an estimate and update with exact date once known) *Trainee Type (These questions will be used to query trainees for Progress Report, Performance Measures and similar functions.) *Upon completing their training, will the trainee qualify as a: (Check one) ( Long-Term Trainee? (300+ hours upon completion of training) ( Intermediate Trainee? (40-299 hours upon completion of training) Individuals whose entire training program is less than 40 hours may be captured in the Short Term Trainee mini dataset. Demographic information on the number of individuals trained through Short-term or Community Training programs is captured in the Activities dataset. *Support Type Check all categories to describe any program-related financial support that the trainee is currently receiving. (check all that apply) Core Grant Funding Other Funding ( MCH Core ( Clinical Fees ( MCH Autism Supplement ( Academic Department ( ADD ( Internship ( OSEP ( Fellowship/Scholarship ( Other ( None/Not Applicable *What MCH support did the trainee receive? (Required if applicable) Stipend $_______________ Tuition & Fees $_______________ Travel Allowance $_______________ Total $_______________ *Product(s) Produced by the Student this year (Required if applicable) (Must complete Product entry form for each new product.) ( New ( Existing (linkable) Presentation(s) by the Student this year: Presentation Name:______________________________________________________________________________ Date:________________________________ Venue:___________________________________________________ OPTIONAL: Type of Participation: (Check all that apply) Didactic Clinical Research Practicum/Field Work Other Please Specify: ___________________ Which of the following training curricula is the trainee completing (independent of trainees funding source/s)? (Check all that apply) LEND UCEDD OSEP Pediatric Residency Other Please Specify: ______________________ Not Applicable FY09 NIRS Trainee Paper Form-LEAH, PPC, DBP- Page PAGE 2 of NUMPAGES 4 % 1 6 : ? @ R V ] ^ i j } ~ rcrQ@ h h. CJ OJ QJ ^J aJ #h h8 5CJ OJ QJ ^J aJ h 5CJ OJ QJ ^J aJ #h h7F 5CJ OJ QJ ^J aJ hP h5 5hP h7F 5 h hK CJ OJ QJ ^J aJ #h hK 5CJ OJ QJ ^J aJ hK 5CJ aJ h; hK 5CJ aJ hK 5>*CJ OJ QJ ^J %h1 hK 56>*CJ OJ QJ ^J "h1 hK 5>*CJ OJ QJ ^J ? R ^ } e f ; @ gdH" gd^ gd. gdm1J gdm1J d gd. d $d a$gd d gdK $x a$gdK $dh a$gdK + 1 : d f ygXgF5 h hm1J CJ OJ QJ ^J aJ #h h 5CJ OJ QJ ^J aJ h 5CJ OJ QJ ^J aJ #h h. 5CJ OJ QJ ^J aJ #h hN 5CJ OJ QJ ^J aJ #h h7F 5CJ OJ QJ ^J aJ h h7 CJ OJ QJ ^J aJ #h h7 5CJ OJ QJ ^J aJ #h h 3 5CJ OJ QJ ^J aJ hi{ 5CJ OJ QJ ^J aJ h h. CJ OJ QJ ^J aJ h CJ OJ QJ ^J aJ f g v x y ɸ털saP