The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

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Required format:

smY64xFUTn8gAIQnq7WpVsAd7A8CGNnRt2WCkPvycsDiVaIedSsmswaNrDph9L43eVhYnDpnfrkH8hUFQhmsN7KWDwhQdbiaY3o5eE

ADH Student Experience Project Interest Form

Please complete the questionnaire below. The information provided in this form will be used for the purpose of student placement and will be treated confidentially, and the information that you provide will help match you with the program at the Arkansas Department of Health that best suits your interests.

Thank you!

First Name

Last Name

Do you consider yourself to be Hispanic/Latino?

Yes

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Please select the options that best describes your race.

Native American or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Other

If you selected other, please describe.

What is your gender?

Permanent Address

Phone number

Personal Email

School email

School Name/Institution

What degree are you pursuing?

What year of your academic program are you in?

If you are pursuing a degree where you are able to establish a concentration, which concentration did you select?

Please provide your academic advisor's name, phone number, and email address.

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Which Department(s) or Office(s) at ADH are you interested in working with?

Have you discussed a specific potential project with anyone at ADH?

Yes

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If yes, please provide the name of the contact at ADH.

How many hours do you have available to work per week?

What times do you have available to work on your tasks at the Arkansas Department of Health?

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Please list your availability for an interview with ADH program staff.

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Per the Americans with Disabilities Act, are there any reasonable accommodations that would help you complete your tasks?

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Have you worked at the Arkansas Department of Health in any capacity before?

Yes

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Please provide details

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Do you have any previous public health work experience?

Yes

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Please provide details.

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List your specific skills or qualifications relevant to the position or project you are interested in.

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List any relevant courses or training you have had that may contribute to the completion of this project.

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What experience do you hope to gain by completing your project(s) at the Arkansas Department of Health?

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I acknowledge that any grade attached to this experience is based on my performance and is therefore my responsibility.

Yes

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I acknowledge that, if I fail to perform the duties that were agreed upon for this experience, the ADH program can relieve me of my responsibilities at any time.

Yes

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I confirm that I am authorized to work in the United States and will provide necessary documentation upon request.

Yes

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Please sign your first and last name here.

* must provide value

Add signature

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.