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Bravo Zulu Registration

Initial Demographics

Form LR-2; DV-1 (Hispanic Q 3), DV-2 (Disadvantaged Q 8); DV-3 (Rural background Q 1f-1g), INDGEN Subforms (all - Q8), IND-GEN Block 3 (Q5), Block 4 (Q2), Block 6a (Q1c), Block 6 (Q3), Block 7 (Q4), Block 8 (Q1f-1g), Block 9 (Q8), Block 10 (Q6-7), Block 11 (Q15-16), Block 12 (Q17), Block 15 (Q12-13), Block 15 (Q9), Block 16 (Q18-25), Exp-2 Block 3(Q18-25)

Form CE-1: Block 9, 9a-9c (Location of workplace) //
This training is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,905,868 with 0% financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.

We are required to collect data and report that information in a group format.  Please complete the below form to assist us in planning future trainings and receiving continued funding.

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