Prefix: , Other:
First Name:
Last Name:
Degree(s): (Separated by commas; no periods)
Title:
Organization Name:
Organization Type: , Other (Please Specify):
  If academic institution:
Type of School: , Other (Please Specify):
Name of office or department:
Email:
Website address:
Address:
Address2:
City:
State:
Zip Code:
Country : (if not USA)
Area(s) of Academic /
Pedagogic Expertise (select up to 4)
  Analysis/Needs Assessment
Competency development
Conference planning
Continuing education
Curriculum design
Distance or distributive education
Evaluation
Faculty development
Field experience coordination
Graphic design
Group process facilitation
Information technology/informatics
Interprofessional education
Leadership Development
Public Speaking
Scientific writing/Publications
Student assessment

Other:
Area(s) of Expertise by prevention/public
health topic (select up to 4):
  Access to Quality Health Services
Aging
Arthritis, Osteoporosis, and Musculoskeletal Conditions
Bioterrorism and/or Public Health Preparedness
Cancer
Diabetes
Disability and Secondary Conditions
Educational and Community-Based Programs
Environmental Health
Epidemiology/Biostatistics
Food Safety
Genetics/Genomics
Health Communication
Health Education and Health Promotion
Heart Disease and Stroke
Health Policy and Advocacy
Health Services Research
HIV/AIDS
Immunization and Infectious Diseases
Injury and Violence Prevention
International/Global Health
Maternal, Infant, and Child Health
Medical Product Safety and/or Quality Improvement
Mental Health and Mental Disorders
Minority Health
Nutrition and Overweight
Occupational Safety and Health
Oral Health
Physical Activity and Fitness
Public Health Infrastructure
Public Health Law
Reproductive Health
Respiratory Diseases
Substance Abuse
Tobacco Use
Vision and Hearing
Women's Health

Other:
Do you require payment for your time?
Preferred modes of consultation:
  Email
Phone
Document review
Interactive video
Web conference
Meet at a conference
You travel to me
I’ll travel to you
Best method to contact you:
Times of year available:
  Summer
Fall
Winter
Spring
Specific months/weeks: (Write in)
OPTIONAL:
Attach brief (<4 page) CV or resume

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