Western States Telegenetics

Are you available on a different date listed above than the one you selected? *

Yes
No

If yes, which other dates are possible for you? (Please select only sessions in your region.)

February 17, 2022 9am-1pm HT/10am-2pm AKT/11am-3pm PT/12pm-4pm MT (WSRGN)
April 5, 2022 8am-12pm HT/10am-2pm AKT/11am-3pm PT/12pm-4pm MT (WSRGN)
March 15, 2022 12pm-4pm ET (NERGN)
March 31, 2022 12pm-4pm ET (NERGN)
April 21, 2022 1pm-5pm ET (NYMAC)
May 11, 2022 1pm-5pm ET (NYMAC)

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First Name *

Last Name *

Phone Number

Cell Number *

Street Address *

City *

State *

Zip Code *

NSGC User ID #

For Certified Genetic Counselors who would like to receive CEUs for completion of this training, we will need your NSGC User ID number. You may obtain one even if you are not an NSGC member. Follow this link and then click on "download this instructional handout" in the text of the first section on the page for further instructions. https://www.nsgc.org/page/ceuapproval

Have you provided services through telemedicine before? *

Yes
No

What do you hope to learn in this telegenetics training program? *

Occupation *

Please check all that apply.

Other Occupation

If your profession was not listed above, please enter it here

Current Place(s) of Employment or Education *

Graduation Year *

The year you completed your graduate degree. If you are a student, please enter your expected year of graduation.

Years of Practice *

5 years or fewer
More than 5 years
n/a

What type of setting(s) do you currently work in? *

Please check all that apply. If your category of work setting is not listed, click on "add new choice" and enter it there.

Employment Status *

Full time
Part time
n/a

Part Time Employment

If you are employed on a part time basis, please indicate the % FTE here.

Do you serve patients in the following categories? *

Please check all that apply.

Covered by Medicaid
Ethnic minority backgrounds
Living in rural areas
Living in areas with a shortage of primary care providers (Health Professional Shortage Areas [HPSA])
Not sure
n/a

Region (Students, please indicate the region where you hope to practice.) *

If you do not know what Regional Genetics Network you a part of please go to http://www.nccrcg.org/ to find out.

CV *

Document can only be in PDF, DOC, DOCX, or ODT format and no more than 2MB in size.

File name:

File size:

Are you a US citizen or permanent US resident? *

Since this training is federally funded, additional documentation is necessary to process your travel reimbursement if you are accepted into the program. As a result, preference may be given to U.S citizens and permanent residents.

Yes
No

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