PROFESSIONAL DEVELOPMENT SURVEY
We are interested in learning more about the classes you and your co-workers may be interested in taking through the Education Fund. Help us to develop the classes you want and need. Complete our survey online today! Or download and fax it to 866.824.9530 Toll Free.

Name:*
Employer:*	Kaiser Southern California Kaiser Northern California Catholic Healthcare West-CA Catholic Healthcare West NV Alameda Hospital Antelope Valley Hospital Brotman Medical Center Children's Hospital & Research Center Oakland Chinese Hospital College Vista Convalescent Hospital Covenant Care Daughters of Charity Hospital El Camino Hospital Evergree New Hope HCA Kaiser - Colorado Kindred Healthcare L.A. Gay & Lesbian Center Longwood Management Olympia Medical Center Salinas Valley Memorial Healthcare SunMar Sun Healthcare Group Valley Health System Washington Hospital Watsonville Community Hospital Western Medical Center - Anaheim
Facility:*
Department:*
E-mail:
Home/Work/Cell Phone: *
Classification:*	Registered Nurse LVN/CNA-Acute Care LVN/CNA-Long Term Care Behavioral Health Professional Dietitian Respiratory Therapist Radiologic Technologist/Other Imaging Tech Audiologist/Speech Pathologists Other
Location:*	Los Angeles Inland Empire San Diego Bay Area Central Coast Central Valley Las Vegas Portland Colorado
Continuing Education*
	I am required to complete continuing education units to maintain my license or certificate Yes No
	Have you taken courses with us before? Yes No
I would like to see the following CE workshops offered by the Education Fund (ex: Law & Ethics, PTSD, Hemodynamic Monitoring, OB Updates, Trauma Radiology, Ventilators and Trach Care, Topics on Obesity and Diabetes, Memory Loss and Alzheimers):    Course                                                                               Recommended Instructor/Contact Info
*Required

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Please send email before returning to site. Thank you.

Or download SEIU UHW-West Professional Education Survey
and fax it to us at 2866.824.9530 Attn: Professional Development.