2024 Registration - Strong Families AZ

Check all that apply*

June 18, 2024 – High Risk Perinatal Program (HRPP) Conference Agenda

Contact Information*

Title First Last

Preferred Pronouns

Job Title*

Name of Organization*

Organization Mailing Address*

Street Address Address Line 2 City State ZIP Code

Direct Office Telephone*

Cell Phone*

Email*

Enter Email Confirm Email

Attendance Certificates:

A certificate for Continuing Education Credits (CECs) for the High Risk Perinatal Program (HRPP) Conference will be individually addressed to each recipient and emailed after the conference.

Continuing Education Credits:*

I am a Registered Nurse and am interested in receiving Continuing Education Credits (CECs) for my participation in the June 18 High Risk Perinatal Program (HRPP) Conference.

I am not a Registered Nurse but am interested in receiving CECs (i.e. Physician, Social Worker, Therapist).

I am not interested in receiving Continuing Education Credits (CECs).

Please Enter Registered Nurse License Number (Required for CECs):

Will you use this continuing education opportunity for maintaining your certification or licensure?

Yes

Don’t know

Do you come from a rural background?

Yes

Don’t know

Do you come from an economically or environmentally disadvantaged background?

Yes

Don’t know

Do you work in a Medically Underserved Community Setting (MUCS)?

Yes

Don’t know

Do you work in a Primary Care setting?

Yes

Don’t know

What is your professional discipline as it relates to the High Risk Perinatal Program?

Other Healthcare Profession not listed. Describe below

Please Describe Your Professional Discipline

Only needed if you selected “Other HRPP professional role” or “Other” in the above question.

What is your employment setting as it relates to the High Risk Perinatal Program?

Please Describe Your Employment Setting

Only needed if you selected “Other HRPP employment setting” in the above question.

In what year did you begin practicing in this setting?

With what gender do you identify?

Male

Female

Non-Binary

Prefer not to say

General Demographic information

The following data helps the planning committee create improved content and professional training programs. This data will be confidential and will not be shared or sold.

What is your role in your organization as it relates to home visiting? (Check all that apply.)*

Please Describe Your Role*

Which County(ies) or Tribal Area(s) do you serve? (check all that apply):

Counties:*

Tribal Areas:*

What Home Visiting Program model(s) are you trained or certified to use? (Check all that apply)*

If (Other) please describe*

How long have you been in your current job/position?*

What is your approximate age?*

With which race/ethnicity do you most closely identify*

What is your highest level of education completed?*

Which language(s) do you use regularly in your work?*

Check all that apply.

English

Spanish

Other

Please indicate other language(s):*

How would you prefer to receive future training? (Check all that apply)*

Check all that apply

One-on-one training or coaching

In-person single-day training class

In-person multi-day class or conference

Self-paced online training modules available to me at any time

Interactive online webinars provided live at specific times only

What is the most time you would be willing to travel by car to receive in-person training?*

Less than an hour (generally within my county of work or residence)

One-to-two hours (generally in a neighboring county)

More than two hours (generally a central urban location outside my county, such as Phoenix/Tucson/Flagstaff).

Have you attended the High Risk Perinatal Program Conference before?*

Check all that apply.

What other training topics might you find useful or be interested in for future conferences?

General comments for the conference planning team:

HRPP Email Opt-In

I would like to receive periodic emails from the High Risk Perinatal Program with the Arizona Department of Health Services regarding conferences, trainings, and other professional development opportunities.

Comments

This field is for validation purposes and should be left unchanged.

High Risk Perinatal
Program Conference

Improving Outcomes:
The Impact of Care Continuity

June 18, 2024

Conference Attendance – June 18, 2024

Attendance Certificates:

General Demographic information

High Risk PerinatalProgram Conference

Improving Outcomes:The Impact of Care Continuity

June 18, 2024

Conference Attendance – June 18, 2024

Attendance Certificates:

General Demographic information

High Risk Perinatal
Program Conference

Improving Outcomes:
The Impact of Care Continuity