Section I: Basic Contact Information

FY 2015 AUCD Directory Paper Form for UCEDD/LEND Users

Section I: Basic Contact Information.

*First Name ______

*Last Name ______

Degree ______

*Phone ______

Secondary Phone ______

£ Subscribe to AUCD Digest

*Email ______

*User Name ______

*Password ______

(Username and password must be at least 6 characters long. Letters, numbers, and symbols may be used. Not case sensitive.)

Work Address

*Address line 1 ______

Address line 2 ______

*City ______

*State ______

*Zip/Postal Code ______

Section II: Additional Information.

*Position The system allows a person to be listed with multiple positions if appropriate. Check all the positions below that apply. Your entry will be validated by the administrator at your site.

Leadership
UCEDD Director / LEND Director
Acting UCEDD Director / Acting LEND Director
Co-UCEDD Director
Associate UCEDD Director / Co-LEND Director
Associate LEND Director
Leadership Administrative Staff:
Primary Activity Coordinators
Adult Services / Pediatric Services
Clinical Services / Person Centered Planning
Community Support / Research
Cultural Diversity / Technical Assistance
Data / Vocational Rehabilitation/Employment
Distance Learning / Training Director
Early Intervention / Community Education Director
Exemplary Services / Medical Director
Information Dissemination / Research Director
Parent/Consumer
Discipline Coordinators
Assistive Technology / Parent/ Family Resources
Audiology / Pediatrics
Dentistry/ Pediatric Dentistry
Education / Pediatrics: Developmental/ Neonatology
Pharmacy
Epidemiology / Physical Therapy
Family Faculty / Psychiatry
Genetics / Psychiatry: Child
Health Administration / Psychology
Medicine / Psychology: Developmental
Neurology / Public Health
Nursing / Respiratory Therapy
Nutrition / Social Work
Occupational Therapy / Special Education
Speech Language Pathology
Type in position titles for these roles
Specialty Resource Contacts
Project/Program/Clinic Contacts

Section II: Additional Information.

*Position The system allows a person to be listed with multiple positions if appropriate. Check all the positions below that apply. Your entry will be validated by the administrator at your site.

Leadership

FY2015 AUCD Directory Paper Form for LEAH Users 2

£ UCEDD Director

£ Co-UCEDD Director

£ Associate UCEDD Director

£ Acting UCEDD Director

£ LEND Director

£ Co-LEND Director

£ Associate LEND Director

£ Acting LEND Director

FY2015 AUCD Directory Paper Form for LEAH Users 2

Primary Activity Coordinators

FY2015 AUCD Directory Paper Form for LEAH Users 2

£ Adult Services

£ Clinical Services

£ Community Support

£ Cultural Diversity

£ Data

£ Distance Learning

£ Early Intervention

£ Community Education Director

£ Exemplary Services

£ Information Dissemination

£ Medical Director

£ Research Director

£ Parent/Consumer

£ Pediatric Services

£ Person Centered Planning

£ Research

£ Technical Assistance

£ Training Director

£ Vocational Rehabilitation/Employment

FY2015 AUCD Directory Paper Form for LEAH Users 2

Discipline Coordinators

FY2015 AUCD Directory Paper Form for PPC Users 3

£ Assistive Technology

£ Audiology

£ Dentistry/ Pediatric Dentistry

£ Education

£ Epidemiology

£ Family Faculty

£ Genetics

£ Health Administration

£ Medicine

£ Neurology

£ Nursing

£ Nutrition

£ Occupational Therapy

£ Parent/ Family Resources

£ Pediatrics

£ Pediatrics: Developmental/ Neonatology

£ Pharmacy

£ Physical Therapy

£ Psychiatry

£ Psychiatry: Child

£ Psychology

£ Psychology: Developmental

£ Public Health

£ Respiratory Therapy

£ Social Work

£ Special Education

£ Speech Language Pathology

FY2015 AUCD Directory Paper Form for PPC Users 3

Type in position titles for these roles, if applicable:

Leadership Administrative Staff ______

Specialty Resource Contacts ______

Project/Program/Clinic Contacts ______

*Primary Discipline (Included in DGIS export) ______

Discipline(s) Check all that apply.

FY2015 AUCD Directory Paper Form for PPC Users 3

£ Audiology

£ Biological Sciences

£ Dentistry-Pediatric

£ Dentistry/Other

£ Disability Studies

£ Education/Special Education

£ Education: Administration

£ Education: Early Intervention/Early Childhood

£ Education: General

£ Epidemiology

£ Family Studies

£ Family/Parent/Youth Advocacy

£ General Medicine

£ Genetics/Genetics Counseling

£ Gerontology

£ Health Administration

£ Human Development/Child Development

£ Interdisciplinary

£ Law

£ Liberal Arts & Sciences, Humanities, & General Studies

£ Medicine-Adolescent Medicine

£ Medicine-Developmental-Behavioral Pediatrics

£ Medicine-Neurodevelopmental Disabilities

£ Medicine-Pediatric Pulmonology

£ Medicine-Pediatrics

£ Mental and Behavioral Health

£ Nursing Family/Pediatric Nurse Practitioner

£ Nursing-General

£ Nursing-Midwife

£ Nursing-Other

£ Nutrition

£ Occupational Therapy

£ Pastoral

£ Pharmacy

£ Physical Therapy

£ Psychiatry

£ Psychology

£ Public Administration

£ Public Health

£ Rehabilitation

£ Respiratory Therapy

£ Social Work

£ Speech-Language Pathology

£ Other - Please specify: ______

FY2015 AUCD Directory Paper Form for PPC Users 3

AUCD Council Membership: (Check all that apply). Checking/unchecking membership adds/removes member from council listservs.

FY2015 AUCD Directory Paper Form for PPC Users 3

£ Council for Interdisciplinary Service (CIS)

£ National Community Education Directors’ (NCEDC)

£ Council on Community Advocacy (COCA)

£ Multicultural Council (MCC)

£ National Training Directors’ Council (NTDC Council)

£ Council on Research and Evaluation (CORE)

£ No Council Membership (none)

FY2015 AUCD Directory Paper Form for PPC Users 3

Professional Areas of Interest and Expertise

Provide a list of “key words,” separated by commas, rather than complete sentences; 200 words or less for each:

Research: ______

______

Education: ______

______

Service: ______

______

Provide an electronic version of:

· a brief (roughly 2 pages) vita or bio—plain text is best

· a photo (photo should be at most 25(width) x 30(height) pixels with file size no greater than 300KB

Section III: This information WILL NOT be available for public search or display:

*Check if you are a

£ Former MCHB-program trainee

£ Former UCEDD trainee

£ None of the above

*Gender

Male

Female

Year of BIRTH (YYYY): ______

*Year HIRED at Center (YYYY): ______

*Race (select one)

White

Black or African-American

American Indian or Alaska Native

Asian (includes Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and other Asian)

Native Hawaiian and Other Pacific Islander (includes Native Hawaiian, Guamanian or Chamorro, Samoan, and other Pacific Islander)

More than One Race

Unrecorded

*Ethnicity (select one)

Hispanic or Latino

Non Hispanic or Latino

Unrecorded

*PRIMARY Employment Role (select one):

Program Director or Associate Director

Senior Faculty: Faculty at the rank of Associate Professor or Professor.

Junior Faculty: Faculty at the rank of Assistant Professor, Lecturer, Adjunct, etc.

Clinical Staff: Individuals with a high degree of expertise and training who specialize in providing clinical services.

Professional Staff: Individuals with a high degree of expertise and training who specialize in performing professional, scientific, or technical activities.

Support Staff: Non-contract employees that include assistants, clerks, coordinators, etc.

Personal relationship with Disabilities (Check all that apply)

£ Person with a disability

£ Person with a special health care need

£ Parent of a person with a disability

£ Parent of a person with a special health care need

£ Family member of a person with a disability

£ Family member of a person with a special health care need

£ None

Subscriptions to AUCD Listserves (Check/Uncheck to manage member subscriptions to the following AUCD listserves)

FY2015 AUCD Directory Paper Form for UCEDD/LEND Users 5

£ Aging

£ Autism

£ Spirituality and Faith

£ Business Managers

£ CDC DH Grantees

£ Disability Studies Discussion

£ Digest

£ Early Intervention/Early Childhood

£ NSIP

£ Emergency Preparedness

£ Email Blasts (Funding opportunities, Resources, Announcements)

£ Health Care Transition

£ International

£ LEND Family

£ Mental Health and Positive Behavioral Supports

£ NCBDD RTOIs Grantees

£ Postsecondary Education

£ Social Work

£ Trainees

£ Web Masters

FY2015 AUCD Directory Paper Form for UCEDD/LEND Users 5

Section IV: Administrative Fields

Member Affiliation(s)

£ UCEDD

£ LEND

*Include this person in EHB upload

Yes

*Member status in online Directory

Display

Do not display

Inactive

Pending Submission

Waiting for Approval

Rejected

FY2015 AUCD Directory Paper Form for UCEDD/LEND Users 5