Profile

Since this curriculum is part of a research project, we are asking you to complete this short profile and pre-module questionnaire. Fields followed by asterisks are required; the rest are optional. Your email address is needed for the notepad and quick messaging features.Your phone number will help us stay in touch with you and get feedback on the modules. All information will be kept confidential by ASU and its representatives; no names will be used in our reports; and contact information will not be distributed to anyone. When you have completed the profile press the Submit Information button and you will be taken to the module.

Type the Required(*) Fields.

<%If Trim(Session("inst_id"))="" then%> <%else dim objConn If IsEmpty(objConn) then open_db() SQLQuery="SELECT Name FROM Institutions WHERE InstitutionID=" & Clng(Session("inst_id")) set rs=Server.CreateObject("ADODB.Recordset") rs.open SQLQuery,objConn,adOpenKeyset %> <%end if%>

User Information

UserName (min. 4 characters) * :

Password (min. 6 characters) * :

Verify Password* :

First Name* :

M.I:

Last Name * :

School/Organization * :

<%=rs(0)%>

E-mail * :

Phone :

City* :

State :

Country :

Age :

Gender :

Male Female

Race/ethnicity :

	American Indian or Alaskan Native
	Asian/Pacific Islander
	Black non-Hispanic
	Hispanic
	White non-Hispanic
	Others

Reason for enrolling in course

* denotes required fields