Thank you for your interest in the AETC training event.
 
Event Title: ARCHIVED VIDEO: ORAL HEALTH VIDEO PART 1: Head and Neck Exam for Healthcare Providers
Date: 10-Apr-17
 
We collect information from each participant in our training activities using the Participant Information Form (PIF). To complete your registration, please follow the instructions below to create or update your Participant Information Form (PIF).

Please fill in your PIF Unique ID Number. To create your unique ID number, enter 4 letters and 4 numbers. Any 4 letters may be chosen, but a suggested format is to use the first 2 letters of your first name and first 2 letters of your last name. The numbers should be the 2-digit month and 2-digit day of your birthday. Using the suggested format, John Smith, May 29, would be JOSM0529. The same unique ID number should be used each time this form is completed.. Why is this necessary This program is part of a federally funded training program.  Because of the government funding source, we need to account for every person who receives training, as well as the number of people who attend multiple trainings.  Please note that this unique identifier does not allow for identification of individual respondents.  As indicated on the form, please create your anonymous PIF unique identification number by entering the month and day of your birth, and the last 4 digits of your Social Security number.
 

PIF ID:  
F F L L M M D D
Name Birth


We collect the following information solely for the purpose of facilitating the on-line registration process for our events. This information is not stored with or connected to your unique PIF ID.
 
First Name:    * required
Last Name:    * required
Email:    * required
Employer/Agency: