Providence Center for Health Care Ethics E-mail Distribution List
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1.
First Name
*
2.
Last Name
*
3.
Providence Employee ID Number (if an not an employee, please leave blank)
4.
Unit or Department and Facility
*
5.
What option best characterizes where you work?
*
-- Please Select --
Acute Care
Administrative Office
Ambulatory Surgery Center
Clinic / Medical Office
Home Health
Hospice
Long-term or Sub-acute Care
Outpatient Behavioral Health
Other (Please specify in the text box below)
6.
What option best characterizes your professional training?
*
-- Please Select --
Business Administration
Clinical Research or Laboratory Science
Dietary / Nutrition
Humanities
Law
Medicine
Nursing
Pharmacy
Physical / Occupational / Speech-Language Therapy
Psychology
Public Health
Respiratory Therapy
Social Work
Spiritual Care / Mission Integration
Other (Please specify in the text box below)
7.
What option best characterizes your current position or role?
*
-- Please Select --
Administrative Leadership (service area/facility/service line)
Clinical Leadership
Direct Care Provider
Regional Leadership
Support Services
Other (Please specify in the text box below)
8.
Email
*
Please enter email address you access frequently. (Does not need to be a work email)
9.
Phone Number
*
10.
Are you a member of a Providence Ethics Committee?
*
Yes
No
11.
Would you like your email address added to our distribution list to receive information on future Ethics learning opportunities?
Yes (includes In-Person as well as Online Viewing opportunities
12.
Questions/Comments