CBSE Student / Resident Worksheet
Community-Based Student Education
Program Coordinator:
Today’s Date:
Registered Center/Dept:
Partners (Select all that apply) Office Use Only
STX - Lower Rio Grande Valley
 TAE - Capital Region
 TAE - Piney Woods Region
 WTX - Big Country
 STX - Mid Rio Grande Border
 TAE - Coastal Region
 TAE - Program Office
 WTX - Desert Mtn(Borderland)
 STX - Program Office
 TAE - DFW Region
 TAE - Victoria
 - WTX Panhandle
 STX - South Central
 TAE - Greater Houston
 TAE - Waco
 - WTX Permian Basin
Region
 STX - South Coastal
 - Unknown
 - WTX Program Office
 TAE - North Central Region
 STX - Southwest Border
 - WTX AHEC of the Plains
 TAE - Northeast Region
Person Tags (Select all that apply)
 Course coordinator
 School Counselor
School Teacher
Prefix (Dr. Mr….):
Last Name:
First Name:
M.I.:
Credential (MD, PhD….):
Address:
City :
State:
Zip code (9 digit if possible):
County:
Primary Phone No:
Fax Phone No.:
Email:
Other Phone No.
Cell Phone No:
Gender:
Primary Ethnicity:
 Male
 American Indian or Alaska
Native
 Asian – Cambodia
 Asian – China
 Asian – India
 Asian – Japan
 Asian – Korea
 Asian – Malaysian
 Asian – Other
 Asian – Pakistan
 Asian – Philippines
 Asian – Thailand
 Female
Date of Birth:
 Asian – Vietnam
 Black or African American
 Hispanic or Latino – Central American
 Hispanic or Latino – Cuban
 Hispanic or Latino – Mexican
 Hispanic or Latino – Other
 Hispanic or Latino - Puerto Rican
 Hispanic or Latino - South American
 Native Hawaiian or Other Pacific
Islander
 White Disadvantaged
 White Non-Disadvantaged
Secondary Ethnicity:
 American Indian or Alaska Native
 Asian – Cambodia
 Asian – China
 Asian – India
Asian – Japan
Asian – Korea
 Asian – Malaysian
 Asian – Other
 Asian – Pakistan
 Asian – Philippines
 Asian – Thailand
 Asian – Vietnam
 Black or African American
 Hispanic or Latino - Central American
 Hispanic or Latino – Cuban
 Hispanic or Latino – Mexican
 Hispanic or Latino – Other
 Hispanic or Latino - Puerto Rican
 Hispanic or Latino - South American
 Native Hawaiian or Other Pacific Islander
 White Disadvantaged
 White Non-Disadvantaged
Description (Tell us a few words about yourself):
Discipline (Select all that apply):
 Not Available / Unknown
 Community Health Worker - CHW
 Nurse Midwives - NM
 Allopathic Medicine - MD
 Health Education/Behavior - HIE
 Nurse Practitioner - NP
 Chiropractic - Chiropractic
 Health Services/Hospital
 Registered Nurse - RN
Administration-HA
 Osteopathic General Practice Clinical Lab Worker
 Nutrition-Dietetics - FNS
DO
 EMT-Paramedic/First Responder
 Clinical Lab Worker-CLS
 Public Health (General Studies) - PH  Health Information Systems/Data
 Optometry
 Veterinary Medicine
Analysis
 Pharmacy - Pharmacy
 Physician Assistant - PA
 Occupational Therapy
 Podiatry - PMPC
 Licensed Practical/Vocational Nurse
 Physical Therapy
(LPN/LVN) - LVN
 Psychiatry
Specialty (select all that apply):
 Dermatology
 Internal Medicine-Infectious Diseases  Pediatrics–Cardiology
 Otolaryngology (ENT)
 Pediatrics-Critical Care
 Internal Medicine–Nephrology
 Family Practice - Family Medicine
 Pediatrics–Endocrinology
 Internal Medicine–Pulmonary
 Family Practice - Complementary
 Pediatrics–Gastroenterology
 Internal Medicine–Rheumatology
Alternative Medicine (CAM)
 Pediatrics–Genetics
 Med / Peds
 Internal Medicine – General
 Pediatrics Neurology
 Other-specify below
 Dental Assistant
 Dental Hygiene
 General Dentistry - Dentistry
 Clinical Psychology - CP
 Clinical Social Work - SW
 Substance Abuse/Addictions
Counseling
 Pediatrics-Rheumatology
 Public Health
 Psychiatry
 Surgery-General
 Surgery-Cardiothoracic Surgery
 Surgery-Neurosurgery
Information for this form is provided voluntarily. AHEC is required to report information about program participants. Data will be kept private to the extent allowed by law and will be referenced
periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form. Please type or print clearly.
CBSE Student/Resident Worksheet
Page 1
06-18-13
 Internal Medicine–Allergy
 Internal Medicine–Cardiology
 Internal Medicine–Endocrinology
 Internal Medicine–astroenterology
 Internal Medicine–Geriatrics
 Internal Medicine–Hematology/Oncology
 OB / Gyn
 Ophthalmology
 Orthopedics
 Pediatrics–General
 Pediatrics-Allergy
Hematology/Oncology
 Pediatrics-Infectious Diseases
 Pediatrics–Neonatology
 Pediatrics–Nephrology
 Pediatrics–Pulmonary
 Surgery-Oral and Maxillofacial 
Surgery
 Surgery-Plastic Surgery
 Surgery-Urology
 Others
Remarks:
Permanent Address:
City:
Zip (9 digits if possible):
Education Level (already achieved)
 Certification: Clinical Medical Assistant
 Certification: CNA
 Certification: EKG Tech
 Certification: EMT
 Certification: Home Healthcare Aide
 Certification: Pharmacy Tech
 Certification: Phlebotomy Tech
 Certification: Radiology Tech
 Certification: Other
 Associates: AAS
 Associates: ADN
 Associates: Other
Other Phone No.
 Bachelors: BA
 Bachelors: BBA
 Bachelors: BE
 Bachelors: BFA
 Bachelors: BS
 Bachelors: BSN
 Bachelors: Other
 Masters: : MA
 Masters: : MBA
 Masters: MPA
 Masters: MPH
 Masters: MS
Hometown at time of high school graduation (city/state)
Is your hometown considered (select all that apply)
Are you fluent in any other
Languages?please specity)
State:
Permanent Phone No.:
 Masters: MSN
 Masters: MSW
 Masters: Other
 Doctorate: DDS/DMD
 Doctorate: DO
 Doctorate: EdD
 Doctorate: Med
 Doctorate: MD
 Doctorate: PharmD
 Doctorate: PhD
 Doctorate: Other
 Advanced Certification
College graduated:
 Border Area
 Rural
Speak
Speak
1.
2.
Undergraduate Major:
 Urban
 Inner City
 Read
 Read
 Suburban
 Write
 Write
Student Type (select one)
 Fellow
 Intern
 Resident
 Student – Dental
 Student - Graduate Health Professions
 Student - Medical School
 Student - Nursing School
 Student - Pre-Health Professions College
 Student - Undergraduate Health Professions Program
 Student - Occupational & Environmental Sciences
Did you obtain a NHSC (National Health Service Corp.) Scholarship?
 Yes
What type of community would you like to locate to for
ultimate practice?
Name any hobbies, special interests, etc.:
 Border Area
 No
 Inner City
 Rural
 No, but interested
 Suburban
 Urban
Check any services that you are requesting from us (some services may not be available at all centers/depts):
 Were you informed by us about a job opportunity in a training site community?
If so… Address
City
State
Zip (xxxx-xxxx)
-
Information for this form is provided voluntarily. AHEC is required to report information about program participants. Data will be kept private to the extent allowed by law and will be referenced
periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form. Please type or print clearly.
CBSE Student/Resident Worksheet
Page 2
06-18-13