Health Professionals Data Survey (12/29/10)
 
 

The purpose of the Health Professionals Data Survey is to collect information that will assist the State of Texas in identifying healthcare workforce trends.

To successfully submit the survey, questions highlighted in blue text must be answered.

If you have any questions about this survey, contact Brian King at (512)458-7111 (Ext. 2775) or brian.king@dshs.state.tx.us.
 
 
 
Select your health profession:
 
 
 
NAME
 
 
Last Name:
 
First Name:
 
Middle Name:
 
Suffix (e.g., Jr., Sr.):
 
 
 
 
Last 4 digits of Social Security Number:
 
 
 
 
MAILING ADDRESS
 
 
Street Number and Name:
 
 
 
City:
 
 
 
State:
 
 
Zip (e.g., 78756):
 
 
 
 
EDUCATION BACKGROUND AND TRAINING
 
 
Health Professions Degree:
 
 
 
Graduation Year for Health Professions Degree: YYYY
 
 
 
Highest Degree Obtained:
 
 
 
Name of Professional School:
 
 
 
County of Professional School:
 
 
Certification, Registration, or License Number:
 
 
 
Method of Certification, Registration, or License Number:
 
 
Certification, Registration, or License Status:
 
 
 
DEMOGRAPHIC INFORMATION
 
 
Month/Date of Birth: MMDD
 
 
 
Year of Birth: YYYY
 
 
 
County of Birth:
 
 
Sex:
 
 
Ethnicity:
 
 
Race:
 
 
County of High School:
 
 
 
PRIMARY PRACTICE INFORMATION
 
 
Street Number and Name:
 
 
 
City:
 
 
 
State:
 
 
Zip (e.g., 78756):
 
 
 
Number of hours per week at primary practice location:
 
 
 
Description of Primary Practice Setting (e.g., hospital, clinic, school, ambulance, etc.):
 
 
 
Primary Specialty:
 
 
 
Primary Practice County:
 
 
 
SECONDARY PRACTICE INFORMATION
 
 
Description of Secondary Practice Setting (e.g., hospital, clinic, school, ambulance, etc.):
 
 
 
Zip of Secondary Practice (e.g., 78756):
 
 
 
Secondary Practice County:
 
 
 


You will be redirected to the DSHS homepage, if your response is successfully received.
Click the "Submit" button below to submit your feedback.