PC-7, LR-1, LR-2, DV-1, DV-2, DV-3, EXP-1, EXP-2 2018-2019
Academic Institution
Acute Care Services
Ambulatory Practice Sites
Assisted Living Community
Community Health Center (CHC)
Community—based Health Center (e.g.,
free clinic)
Community Health Center–Other
Dentist Office
Emergency Room
Federal Government— Agency/Office
FQHC or look-alike
Geriatric Ambulatory Care and
Comprehensive Units
Hospital
Local Health Department
Mobile Clinic/Site
Nurse-managed Health Clinic
Nursing Home
Physician Office
Residential Living Facility
School-based Clinic
Senior Center
Specialty Clinic (e.g., mental health
practice,
rehabilitation, substance abuse clinic)
State Government— Agency/Office
State Health Department
Surgery Clinic
Tribal Health Department
Veterans Affairs Healthcare (e.g., VA
Hospital or Clinic)
Other (Specify):
Did you receive training in a (select all that apply): Primary Care Setting Medically Underserved Area Rural Setting
Which Discipline are you being trained at this site. For those that have an *, please specify specialty (select one):
Student—Allied Health*
Student—Alternative/Complementary
Nursing
Student—Certified Nurse Leader—
Generalist
Student—Certified Nurse Specialist
Student—Certified Nursing Assistant
Student—Community Health Worker
Student—Dental Assistant
Student—Dental Hygiene
Student—Dental School
Student—Dental Therapy
Student—Dietician
Student—Emergency Medical
Technician/Paramedic
Student—Graduate—Allied Health*
Student—Graduate—Clinical Laboratory
Services
Student—Graduate—Health Sciences
Program*
Student—Graduate—Nursing Doctorate*
Student—Graduate—Nursing Masters*
Student—Graduate—Other*
Student—Graduate—Other—Behavioral
Health*
Student—Graduate—Psychology
Student—Graduate—Public Health
Student—Graduate—Social Work
Student—Health Information
Technician
Student—Home Health Aide
Student—Licensed Nursing Assistant
Student—Licensed
Practical/Vocational Nurse
(LPN/LVN)
Student—Medical Assistant
Student—Medical School
Student—NP*
Student—Nurse Anesthetist
Student—Nurse Educator
Student—Nurse Midwife
Student—Nursing Assistant/ Aide
Student—Nursing BS/BSN
Completion
Student— Nursing—Registered
Nurse (RN)
Student—Occupational Therapy
Student—Patient Care/Support
Technician
Student—Pharmacy School
Student—Pharmacy Technician
Student—Phlebotomy Technician
Student—Physical Therapy
Student—Physical Therapy Assistant
Student—Physician Assistant
Student—Podiatry School
Student—Radiological Assistant
Student—Radiological Technician
Student—Rehabilitation Therapy
Student—Respiratory Technician
Student—Speech Therapy
Student—Undergraduate—Allied Health*
Student—Undergraduate—Behavioral Health
Student—Undergraduate—Clinical
Laboratory Services
Student—Undergraduate—Health Sciences
Program*
Student—Undergraduate—Nursing
Student—Undergraduate—Other*
Student—Undergraduate—Psychology
Student—Undergraduate—Public Health
Student—Undergraduate—Radiological
Technician
Student—Undergraduate—Social Work
Other—Nutritionist
Other—Therapies*
Other—Other*
*Please specify area of specialty:
Were there other disciplines that participated in inter-professional team-based learning with you? Yes No
If “Yes” is checked, please answer the following questions.
BEFORE this
program/experience
NOW, after this
program/experience
-Working collaboratively with other health professionals, health care providers,
and community agencies to serve a vulnerable population is worthwhile
-I am knowledgeable about the benefits of participating on an interprofessional
team
-I have the skills necessary to participate in interprofessional team
-I plan to work collaboratively with other health professionals, health care
providers, and community agencies to serve vulnerable populations
Enter # of other disciplines who participated with you at (same as training site name)
Allied Health
Alternative/
Complementary Nursing
Emergency Medical
Technician/Paramedic
Health Information
Medicine—Psychiatry
Medicine—Other
Nurse Practitioner (NP)*
Physical Therapy
Physical Therapy
Assistant
