Username

Only lowercase letters allowed (Capital letters not allowed)

Password

Email address

Primary Email Address Type

Personal Business

Secondary Email Address

First name

Last name

Preferred Pronouns

Department

Organization or Company

Principal Employment/Practice Setting

Choose... Academic Health Center Administrative Facility Advocacy Organization AIDS Service Organization (ASO) Capacity Building Partner College/University Community-Based/Retail Pharmacy Community-Based Organization (CBO) Correctional Facility/Institution Faith-Based Organization (FBO) Health Center (e.g., Federally Qualified Health Center, FQHC Look-Alike) Health Clinic Health Services Facility Health Maintenance Organization/Managed Care Organization Hospital/Hospital-Affiliated Clinic Indian Health Services Local Health Department Military Health System/Veteran’s Health Non-Profit Organization Pharmaceutical Manufacturer Private Practice (Solo/Group) Rural Health Center Social Service Organization State Health Department Third-Party Payor Not Affiliated with an Organization Other

Principal Employment/Practice Setting - Other

Job Title

Degree(s)

Primary Function/Profession

Choose... Administrator Advocate Case Management Clergy/Faith-based Professional Community Health Worker Dentist Dietician/Nutritionist Disease Intervention Specialist Finance/Fiscal Manager Harm Reductionist/Risk Reductionist Health Education Specialist Health Navigator Licensed Practical Nurse Medical Assistant Medical billing Mental Health Case Manager Mental Health Professional Nurse Practitioner Nursing Case Manager Occupational therapist Outreach Worker Patient/Consumer Pharmacist Pharmacy Technician Psychologist Physician Assistant Physician Registered Nurse Researcher Social Worker Student Substance Abuse Counselor/ Professional Other Provider/Professional

Primary Function/Profession - Other

Primary Area of Specialization/Focus

Choose... Addiction Medicine Allergy and clinical immunology Cardiology Critical care/ intensive care Dentistry Dermatology Diabetes Emergency medicine Endocrinology Family medicine Gastroenterology General practice Geriatrics Hematology Hepatology HIV/AIDS Hospice/palliative care Infectious Diseases Internal Medicine Neonatal/Perinatal Medicine Nephrology Neurology Neurosurgery Nutrition OB/GYN and Women’s Health Oncology Ophthalmology Otolaryngology Pain Management Pathology Pediatrics Preventative medicine Psychiatry Psychology public/community health Pulmonary medicine Radiology Rheumatology Sleep medicine Sports Medicine Surgery Transplantation Urology Vascular medicine Other

Primary Area of Specialization/Focus - Other

Continued Education Credits

Choose... Yes No

Continuing Education Credit Type

American Medical Association (MDs, DOs) American Medical Association (NPs, PAs) American Academy of Physician Assistants (PAs) Accreditation Council for Pharmacy Education (Pharmacists) American Nurses Credentialing Center (Registered Nurses) American Psychological Association (Psychologists) Association of Social Work Boards (ASWB) Certificated Health Education Specialists Credits/Master Certified Health Education Specialist (CHES/MCHES) Certified Public Health Recertification (CPH) None

ABIM#

CHES/MCHES#

NABP#

NBPHE#

NPI#

RLN#

Other License Number

Birth Month

Choose... 01 02 03 04 05 06 07 08 09 10 11 12

Birth Day

Choose... 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Initial License Year

Choose... 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Country

Choose... Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (the Democratic Republic of the) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (the Democratic People's Republic of) Korea (the Republic of) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova (the Republic of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, the United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

City/town

Business Phone

Business Address 1

Business Address 2

Business City

Business State, Province or Territory

Choose... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia American Samoa Guam Northern Mariana Islands Puerto Rico United States Minor Outlying Islands Virgin Islands, U.S.

State(s) Licensed

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia American Samoa Guam Northern Mariana Islands Puerto Rico United States Minor Outlying Islands Virgin Islands, U.S.

DC Ward

Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8

Postal Code

Birth Year

1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Gender Identity

Choose... Agender Androgyne Demigender Genderqueer/ Gender fluid Man Questioning/Unsure Trans man Trans woman Woman Other

Racial Background

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Other

Origin

Yes No

Spoken Languages

Amharic, Somali, or other Afro-Asiatic languages Arabic Armenian Chinese Creole English French German Greek Gujarati Haitian Hebrew Hindi Hmong Ilocano, Samoan, Hawaiian, or other Austronesian languages Italian Japanese Khmer Korean Malayalam, Kannada, or other Dravidian languages Nepali, Marathi, or other Indic languages Persian Polish Portuguese Punjabi Russian Serbo-Croatian Spanish Swahili other languages of Central, Eastern, and Southern Africa Tagalog Tamil Telugu Thai, Lao, other Tai-Kadai languages Ukrainian or other Slavic languages Urdu Vietnamese Yiddish, Pennsylvania Dutch or other West Germanic Languages Yoruba, Twi, Igbo, or other languages of Western Africa Other Asian languages Other Indo-European languages Other

Graduation Year

1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Employment Status

Full-Time (32 hours or more hours per week) Part-Time (less than 32) Unemployed and looking for work Unemployed and NOT looking for work Contractor/Consultant Student Retired Homemaker Disabled, not able to work Other Prefer not to answer

Gender Identity - Other

Employment Status - Other

Racial Background - Other

Spoken Languages - Other

Are you a licensed provider?

Choose... I am not a licensed provider Acupuncturist Certified Addiction Counselor Chiropractor CNS DDS Dietitian DO LCSW LPC LPN Massage Therapist MD Mental Health Counselor NP Nutritionist PA Pharm Tech PharmD Podiatrist Psychologist Resident/Fellow RN Substance Abuse Counselor Other

Licensed Provider Other

Highest Degree Earned

Choose... AS/AAS BA/BS MA/MS MPH MD PhD/EdD DrPH ScD PharmD DDS DO Not Applicable/No Degree

Degree(s)/Credentials

Initial License Year

Choose... Choose... 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 NA

What percentage of your time is devoted to each of the following areas?

Percentage of Time Spent in Patient Care

Percentage of Time Spent in Research

Percentage of Time Spent in Teaching/Instruction

Percentage of Time Spent in Administration

Security question

There are required fields in this form marked .