Assessment Services - Participant Agreement Fields marked with an * are required Participant Information Referring Organization Authorization Release AGREEMENT Participant authorizes and CPEP Obligations Dispute Resolution - Miscellaneous Terms & Conditions Participant Information Salutation * - None - Dr. Mr. Ms. Mrs. Prof. First Name * Middle Initial * Last Name * Degree * - Select Degree - M.D. D.O. P.A. A.A. A.A.S. A.D. A.P.R.N. A.R.N.P. A.S. Au.D. B.A. B.D.S. B.H.Sc. B. Pharm. B.S. B.S.N. B.Sc. B.Sc. P.T. B.Sc.Pharm. B.V.Sc. C.N.M. C.Psych. C.R.N.A. D.C. D.Ch. D.D. D.D.H. D.D.S. D.M.D. D.M.Sc. D.N.A.P. D.N.P. D. Opt D.P.M. D.P.N. D.P.T. D.V.M. Ed.D. F.D. F.N.P. F.R.C.S.C. J.D. L.C.S.W. L.M.C.C. L.M.H.C. L.M.H.P. L.I.M.H.P. LL.B. L.M.T. L.P.C. L.P.N. M.A. M.B.A. M.B.B.S. M.B.Ch.B. M.C. M.Div. M.Ed. M.H. M.H.A. M.L.T. M.M.Sc. M.N.Sc. M.P.A. M.P.A.S. M.P.H. M.P.T. M.S. M.Sc. M.S.N. MSN-Ed M.S.W. N.D. N.P. O.D. O.T. O.T.A. P.A.C. Pharm.D. Ph.D. P.M.H.-N.P. Psy.D. P.T. P.T.A. R. Ph. R.D.H. R.D.P.N. R.M.T. R.N. R.P. R.R.T. Other Not Applicable What is your Primary Practice Specialty? * < Select > Abdominal Surgery Acupuncture Addiction Medicine Addiction Psychiatry Administrative Medicine Adolescent Medicine Allergy and Immunology Anatomic Pathology Anesthesiology Bariatric Medicine Bariatric Surgery Behavioral Health Cardiology Cardiology - Interventional Cardiothoracic Surgery Cardiovascular Disease Cardiovascular Surgery Child/Adolescent Psychiatry Child Neurology Chiropractic Clinical Pathology Colon and Rectal Surgery Cosmetic/Aesthetic Medicine Critical Care Dental Dermapathology Dermatology Diabetes Diagnostic Radiology Emergency Medicine Endocrinology Facial Plastic Surgery Family Medicine Family Medicine - No OB Forensic Pathology Forensic Psychiatry Gastroenterology General Practice General Preventive Medicine General Surgery Geriatric Medicine Geriatric Psychiatry Gynecologic Oncology Gynecology Hand Surgery Head and Neck Surgery Hematology Hematology Oncology Holistic Medicine Hospital Medicine Immunology Immunopathology Infectious Disease Internal Medicine Massage Therapy Maternal and Fetal Medicine Medical Microbiology Medical Oncology Medical Toxicology Midwifery Musculoskeletal Oncology Neonatal-Perinatal Medicine Nephrology Neurology Neuropathy Neuroradiology Neurosurgery Nuclear Medicine Nuclear Radiology Nurse Anesthetist Nurse Midwife Nursing Nutrition Obesity Medicine Obstetrics Obstetrics and Gynecology Occupational Medicine Oncology Opthalmology Optician Optometry Oral and Maxillofacial Surgery Orthopedic Surgery Orthopedic Surgery of the Spine Otolaryngology Otology Otorhinolaryngology Pain Management-Interventional Pain Management-Medical Pain Medicine Palliative Medicine Pathology Pediaric Allergy Pediatric Anesthesiology Pediatric Cardiology Pediatric Critical Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology/Oncology Pediatric Medicine Pediatric Nephrology Pediatric Neurodevelopmental Disabilities Pediatric Neurology Pediatric Rheumatology Pediatric Surgery Pharmacy Physical Medicine and Rehabilitation Physical Therapy Physician Assistant Plastic Surgery Podiatry Primary Care Psychiatry Psychoanalysis Psychology Psychopharmacology Psychotherapy Pulmonary Critical Care Pulmonology Radiation Oncology Radiology Radiology - Interventional Reproductive Endocrinology Respiratory Therapy Rheumatology Sports Medicine Surgical Oncology Thoracic Surgery Trauma Surgery Urgent Care Urogynecology Urology Not Available Vascular Surgery Veterinary Other Subspecialty < Select > Abdominal Surgery Acupuncture Addiction Medicine Addiction Psychiatry Administrative Medicine Adolescent Medicine Allergy and Immunology Anatomic Pathology Anesthesiology Bariatric Medicine Bariatric Surgery Behavioral Health Cardiology Cardiology - Interventional Cardiothoracic Surgery Cardiovascular Disease Cardiovascular Surgery Child/Adolescent Psychiatry Child Neurology Chiropractic Clinical Pathology Colon and Rectal Surgery Cosmetic/Aesthetic Medicine Critical Care Dental Dermapathology Dermatology Diabetes Diagnostic Radiology Emergency Medicine Endocrinology Facial Plastic Surgery Family Medicine Family Medicine - No OB Forensic Pathology Forensic Psychiatry Gastroenterology General Practice General Preventive Medicine General Surgery Geriatric Medicine Geriatric Psychiatry Gynecologic Oncology Gynecology Hand Surgery Head and Neck Surgery Hematology Hematology Oncology Holistic Medicine Hospital Medicine Immunology Immunopathology Infectious Disease Internal Medicine Massage Therapy Maternal and Fetal Medicine Medical Microbiology Medical Oncology Medical Toxicology Midwifery Musculoskeletal Oncology Neonatal-Perinatal Medicine Nephrology Neurology Neuropathy Neuroradiology Neurosurgery Nuclear Medicine Nuclear Radiology Nurse Anesthetist Nurse Midwife Nursing Nutrition Obesity Medicine Obstetrics Obstetrics and Gynecology Occupational Medicine Oncology Opthalmology Optician Oral and Maxillofacial Surgery Orthopedic Surgery Orthopedic Surgery of the Spine Otolaryngology Otology Otorhinolaryngology Pain Management-Interventional Pain Management-Medical Pain Medicine Palliative Medicine Pathology Pediaric Allergy Pediatric Cardiology Pediatric Critical Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology/Oncology Pediatric Medicine Pediatric Nephrology Pediatric Neurodevelopmental Disabilities Pediatric Neurology Pediatric Surgery Pharmacy Physical Medicine and Rehabilitation Physical Therapy Physician Assistant Plastic Surgery Podiatry Primary Care Psychiatry Psychoanalysis Psychology Psychopharmacology Psychotherapy Pulmonary Critical Care Pulmonology Radiation Oncology Radiology Radiology - Interventional Reproductive Endocrinology Respiratory Therapy Rheumatology Sports Medicine Surgical Oncology Thoracic Surgery Trauma Surgery Urgent Care Urogynecology Urology Vascular Surgery Veterinary Other Not Available Pediatric Rheumatology Specialty being assessed: * < Select > Abdominal Surgery Acupuncture Addiction Medicine Addiction Psychiatry Administrative Medicine Adolescent Medicine Allergy and Immunology Anatomic Pathology Anesthesiology Bariatric Medicine Bariatric Surgery Behavioral Health Cardiology Cardiology - Interventional Cardiothoracic Surgery Cardiovascular Disease Cardiovascular Surgery Child/Adolescent Psychiatry Child Neurology Chiropractic Clinical Pathology Colon and Rectal Surgery Cosmetic/Aesthetic Medicine Critical Care Dental Dermapathology Dermatology Diabetes Diagnostic Radiology Emergency Medicine Endocrinology Facial Plastic Surgery Family Medicine Family Medicine - No OB Forensic Pathology Forensic Psychiatry Gastroenterology General Practice General Preventive Medicine General Surgery Geriatric Medicine Geriatric Psychiatry Gynecologic Oncology Gynecology Hand Surgery Head and Neck Surgery Hematology Hematology Oncology Holistic Medicine Hospital Medicine Immunology Immunopathology Infectious Disease Internal Medicine Massage Therapy Maternal and Fetal Medicine Medical Microbiology Medical Oncology Medical Toxicology Midwifery Musculoskeletal Oncology Neonatal-Perinatal Medicine Nephrology Neurology Neuropathy Neuroradiology Neurosurgery Nuclear Medicine Nuclear Radiology Nurse Anesthetist Nurse Midwife Nursing Nutrition Obesity Medicine Obstetrics Obstetrics and Gynecology Occupational Medicine Oncology Opthalmology Optician Oral and Maxillofacial Surgery Orthopedic Surgery Orthopedic Surgery of the Spine Otolaryngology Otology Otorhinolaryngology Pain Management-Interventional Pain Management-Medical Pain Medicine Palliative Medicine Pathology Pediaric Allergy Pediatric Cardiology Pediatric Critical Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology/Oncology Pediatric Medicine Pediatric Nephrology Pediatric Neurodevelopmental Disabilities Pediatric Neurology Pediatric Rheumatology Pediatric Surgery Pharmacy Physical Medicine and Rehabilitation Physical Therapy Physician Assistant Plastic Surgery Podiatry Primary Care Psychiatry Psychoanalysis Psychology Psychopharmacology Psychotherapy Pulmonary Critical Care Pulmonology Radiation Oncology Radiology Radiology - Interventional Reproductive Endocrinology Respiratory Therapy Rheumatology Sports Medicine Surgical Oncology Thoracic Surgery Trauma Surgery Urgent Care Urogynecology Urology Vascular Surgery Veterinary Other Not Available Personal Email * Work Email Country * United States Canada State * - Select State - Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Unknown Mailing Address * City * Zip * Mobile Phone * Work Phone Fax Preferred Method of Contact * Email Mail Phone Divider Copy The Participant is a healthcare professional licensed in the State(s) of: The Participant is a healthcare professional licensed in the State(s) of: License Country United States Canada License State - Select State - Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Unknown License Number License Status < Select > Active, no Restr or Stip Active, with Restr or Stip Inactive Revoked, or Suspended Additional License State? Divider Are there any specific accommodations that might impact your participation in the Program (i.e. language, physical disability, etc.) 255 of 255 Character(s) left Divider Copy Copy Demographic Information: Demographic Information: Country of Birth: < Select > United States of America Afghanistan Albania Algeria Angola Argentina Armenia Australia Austria Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bolivia Brazil Bulgaria Burkina Faso Cambodia Cameroon Canada Chad Chile China Colombia Comoros Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Kingdom (UK) Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe Other What year did you move to the United States(if applicable)? < Select > 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Primary Language Spoken as a Child < Select > English Arabic Chinese Farsi French German Greek Gujarti Hindi Igbo (Nigerian) Japanese Korean Patois Persian (Iranian) Polish Portugese Punjabi (India) Romanian Russian Spanish Tagalog (Filipino) Telugu Ukrainian Urdu Urhobo (Nigeria) Vietnamese Rate your level of English proficiency: * < Select > Beginner Intermediate Advanced Gender < Select > Male Female Prefer not to answer Other Birthdate (MM-DD-YYYY) * Month-Day-Year format Ethnicity < Select > African African American Asian/PI Caucasian Hispanic Indian (India) Native American Not Available Other If you are a human seeing this field, please leave it empty.
