TEF Enrollment Question Title * 1. Please tell us who you are: Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title * 2. Please mark any of the following programs you are interested in. Preparing to go back to school Going to college or nursing school to earn an LPN or RN Skills Enhancement Classes (for CNAs, LPNs, or Dietary Workers) Improving my skills on the computer Improving quality for my residents I want to move up but I'm not sure about my career goals Obtaining my CNA Certification Obtaining my GED Going to college for another career Other (please specify) Question Title * 3. Please describe your career or educational goals: Question Title * 4. What concerns, if any, do you have about going to class or returning to school? Question Title * 5. How did you hear about the SEIU Healthcare PA Training Fund? Question Title * 6. At which location do you work? Question Title * 7. What is the job title for your current position? Question Title * 8. About how long have you been in your current position? Years Months Question Title * 9. Are you male or female? Male Female Question Title * 10. Which category below includes your age? 17 or younger 18-20 21-29 30-39 40-49 50-59 60 or older Question Title * 11. What is the highest level of school you have completed or the highest degree you have received? Less than high school degree High school degree or equivalent (e.g., GED) Some college but no degree Associate degree Bachelor degree Graduate degree Question Title * 12. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race? White Black or African-American American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander From multiple races Some other race (please specify) Question Title * 13. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group? I am not Spanish, Hispanic, or Latino Mexican Mexican-American Chicano Puerto Rican Cuban Cuban-American Some other Spanish, Hispanic, or Latino group From multiple Spanish, Hispanic, or Latino groups Question Title * 14. In what language do you speak most often? Chinese English French French Creole Korean Polish Russian Spanish Tagalog Vietnamese Other (please specify) Done
