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Individual Profile

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Additional Information

*Position

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Leadership

Leadership Administrative Staff
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Primary Activity Coordinators

Discipline Coordinators

Specialty Resource Contacts
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Project/Program/Clinic Contacts
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*Primary Discipline:
(Included in DGIS export)

Discipline(s):
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*AUCD Council Membership
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Community Education Directors' Council (CEDC)	Council on Community Advocacy (COCA)
Council on Research and Evaluation (CORE)	Multicultural Council (MCC)
National Training Directors' Council (NTDC)	No Council Membership (none)

Professional Areas of Interest and Expertise
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Research
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Education
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Service
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Vita or Bio
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Additional Information

*Check if you are a

Former MCHB-program trainee

Former UCEDD Trainee

None of the above

*Gender

Male

Female

Transgender Man

Transgender Woman

Other

Choose not to disclose/unknown

Other Gender Description

Primary Language

*Do you speak a language other than English at home?

Yes, Spanish
Yes, another language, please identify:
No

If yes how well do you speak English?

Very well
Well
Not well
Not at all

Year of Birth

*Year Hired in MCH Leadership Training Program/ Year Hired at Center

Not affiliated with MCH Leadership Training Program

*Race

	American Indian or Alaska Native refers 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).
	Black or African American refers to people having origins in any of the Black racial groups of Africa.
	Native Hawaiian or Other Pacific Islander refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
	White refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa.
	More than one race includes individuals who identify with two or more racial designations.
	Unrecorded is included for individuals who are unable to identify with the categories

*Ethnicity

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
	Unrecorded

*PRIMARY Employment
Role at Program

Program Director or Associate Director

Senior Faculty: Faculty at the rank of Associate Professor or Professor.

Junior Faculty: Faculty at the rank of Assistant Professor, Lecturer, Adjunct, etc.

Clinical Staff: Individuals with a high degree of expertise and training who specialize in providing clinical services.

Professional Staff: Individuals with a high degree of expertise and training who specialize in performing professional, scientific, or technical activities.

Support Staff: Non-contract employees that include assistants, clerks, coordinators, etc.

*Personal relationship
with Disabilities
(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

None

Unrecorded

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