Obesity Certificate Program Interest Form

If you are interested in being part of the third phase of the Obesity Management in Primary Care Certificate Program, and would like to learn more, please complete the form below and answer every question as completely as possible.

First Name*

Last Name*

Email Address*

Phone

City

State

What is your primary occupation?

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Please indicate your primary role:

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Other primary role:

Please indicate your primary specialty:

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Other primary specialty:

Please indicate your primary employer type:

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Other primary employer type:

Please indicate your primary setting in which you practice for your employer:

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Other primary setting for employer:

Are you currently practicing as an PA or NP?

Yes

How many years have you been practicing and working a minimum of 30 hours per week?

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How many patients with obesity do you see weekly?

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How many patients with obesity do you screen for obesity per week?

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How many patients with obesity do you treat per week?

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Please rate your confidence level relative to counseling and treating patients affected by obesity:

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Send me a copy of my responses

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