2018 PHYLA Steering Committee Application

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* 1. First name:

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* 2. Last name:

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* 3. What is your gender identity?

Male

Female

Transgender

Other

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* 4. What is your age?

18-22

23-26

27-30

31-34

35-40

40+

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* 5. Are you currently:

Employed Full-Time (non-student)

Employed Full-Time (and also a student)

Employed Part-Time (non-student)

Employed Part-Time (and also a student)

Full-Time Student

Unemployed, seeking employment

Unemployed, not seeking employment

Other (please specify)

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* 6. What is your highest completed level of education?

High School Diploma

Associate's Degree

Bachelor's Degree

Master's Degree

Doctoral Degree

Other (please specify)

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* 7. Please provide the degree/concentration/major of your highest completed education (e.g. public health, healthcare administration, medical doctor, social work, etc.):

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* 8. For how long have you been working in the field of public health?

Less than 12 months

1-4 years

5-9 years

10-15 years

15+ years

I don't currently work in the field, but I'm interested in learning more!

2018 PHYLA Steering Committee Application

Question Title

* 1. First name:

Question Title

* 2. Last name:

Question Title

* 3. What is your gender identity?

Question Title

* 4. What is your age?

Question Title

* 5. Are you currently:

Question Title

* 6. What is your highest completed level of education?

Question Title

* 7. Please provide the degree/concentration/major of your highest completed education (e.g. public health, healthcare administration, medical doctor, social work, etc.):

Question Title

* 8. For how long have you been working in the field of public health?

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* 9. Please provide the name of your current employer (leave blank if student/unemployed):

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* 10. What is your current job title?