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  2. 2011
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  5. Student Profile (Contact Info)

Student Profile (Contact Info)

Student Profile (Contact Info)
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Hello:
The THR University clinical education department maintains a database containing student contact information for faculty that is also used to track immunization and CPR requirements. You have been asked to submit your profile information via this online tool in order to populate the database more efficiently. The electronic form consists of 21 items and will take you approximately 10 minutes to complete.

Your information will remain strictly confidential. If you have questions at any time about the survey or the procedures, you may contact Jerry Stern at 682-236-6199 or by email at [email protected].

Thank you very much for your time and support. Please start completing the form now by clicking on the Continue button below.
 
 
 
* Semester:
 
 
* Last Name:
   
 
 
* First Name:
   
 
 
 
* Street:
   
 
 
Apartment No.:
   
 
 
* City:
   
 
 
* State:
 
 
* Zip Code:
   
 
 
 
Home Phone:
   
 
 
Cell Phone:
   
 
 
Work Phone:
   
 
 
* Last 4 digits of SSN#:
   
 
 
 
* E-mail address (Please use THR e-mail address if a THR employee):
   
 
 
 
* Where do you currently work?
 
THR
 
Not currently working
 
Other
 
 
 
 
Please select the entity in which you currently work.
 
 
 
THR Employment Status
 
Full time
 
Part time
 
PRN
 
 
 
THR Employee ID#:
   
 
 
 
Number of years at current employer. (Please enter the number of years, i.e., "3" not "three".)
   
 
 
 
* School
 
El Centro
 
TCU
 
UTA
 
Other
 
 
 
 
* Program
 
ADN
 
APBSN
 
CNL
 
Other
 
 
 
 
Student ID
   
 
 
 
* Name:
   
* Contact Phone Number:
   
 
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