Register You Information
(The items marked with
*
must be answered to proceed.)
*
First Name:
*
Last Name:
Title:
Degrees:
*
Organization Name:
*
Address:
*
City:
*
State:
Other Countries
AK
AL
AR
AZ
CA
CO
CT
DE
DC
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
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OK
OR
PA
RI
SC
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TN
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*
Zip Code:
Phone:
*
E-mail:
Organization Type:
Local public health department
State public health department
Tribal community
Academic
Non-profi
Profi
Federal agency
State agency
other
Other - please describe:
Are you a NACCHO member?
Yes
No
Don't know
Jurisdiction Size (population):
0-24,999
25,000-49,999
50,000-74,999
75,000-99,999
100,000-249,999
250,000-499,999
500,000-999,999
1 million +
Type of jurisdiction served by your organization:
County
City
Town/township
Multi-county, disctric, or region
Other
Other - please describe:
How did you become aware of
PACE EH
:
NACCHO newsletters or conferences
Other conference
Other public health organization (e.g. NALBOH, APHA, ASPH, ASTHO, PHF)
State Health Department
From local health department (if respondent is not a LHD)
From a colleague
From a NACCHO member
Journal or trade publication
Internet
NACCHO Website
Academic Institution (e.g., university, school of public health)
Other
Other - please name:
Will you be the lead organization for conducting
PACE EH
? If not, who/what type of organization will be?
How do you intend to use
PACE EH
:
