Clinical Rotation Request
Alaska AHEC Application
Resource Links for Graduates
Health Careers Program Participation Survey
Information for this form is provided voluntarily. AHEC is required to report information about program participants from our funding agency (HRSA). Data will be kept private to the extent allowed by law and will be referenced periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form.
Indicates required field
What community did you grow up in?
Date of birth
Are you Hispanic/Latino?
Racial/Ethnic Background (mark all that apply)
American Indian/Alaska Native
Asian (Chinese, Filipino, Japanese, Korean, Asian Indian, Thai)
Black or African American
Native Hawaiian/Other Pacific Islander
White or Caucasian
If "other" please specify:
I qualify for school lunch assistance or other lower income program.
I don't know
One or both of my parents graduated from college.
I don't know
Please answer the following questions:
On a scale of 1 to 5, how would you rate your overall activity experience?
How likely are you to go into a health career?
How much has this activity influenced or impacted your interest in a health career?
I am no longer interested in a health career
I am less interested in a health career
My level of interest hasn't changed
I am more interested in a health care career
I am much more interested in a health care career
To what extent do you feel this activity has increased your knowledge of health careers?
If you were to select 3 health careers you might do in the future, what would those be?
I don't know
I am not interested in health careers at this time
We want our health career presentations or activities to be useful and provide you with valuable information to help you prepare for the future. Please share your thoughts about the quality of this activity and what additional information (or topics) you would like to hear about:
Have you attended other AHEC activities or discussed health career opportunities with an AHEC staff member? If so please identify. (Choose all that apply)
No, I have not participated in any other AHEC activities.
Career or Health Fair
Hospital or Health Facility Tour
Would you like to receive emails notifications about upcoming programs?
Not at this time
We hope to see you again at a future AHEC sponsored health career activity!
Interior Alaska Area Health Education Center (AHEC) - In Partnership With: Foundation Health Partners, Chief Andrew Isaac Health Center, and the Interior Public Health Partners.