University of North Carolina at Chapel Hill
School of Public Health
Department of Epidemiology

Fundamentals of Epidemiology (EPID 168)

Participant information form

If you wish to take or audit EPID 168, please provide this information for the class roster to be distributed to all course participants.(Back to EPID 168 home page)

YOUR NAME (as in University records)
(first) (middle) (last)

"Please call me" (if you like to be called something other than your official first name)

Undergraduate degree(s) Graduate/professional:

E-MAIL address: P.I.D.:

Day telephone number: OK to distribute? YesNo

Evening telephone number: OK to distribute? YesNo (No calls after: )

Taking class for credit? No, audit /Yes (section: Lab section: )

If you are taking EPID 168 for credit, please provide a "code" that can be used to post your exam scores so that only you can identify them. A family member's telephone number (present or past) is an easy choice. You can also include a mnemonic about what code you provided (e.g., 4459937, Jim's old phone #)

Code: Mnemonic:

Your school/SPH department:

Degree program: Year in program: Specialty or track:

Advisor: Other positions/affiliation(s) if any:

Please list up to 2 epidemiology or research courses you have taken:

1. When?

2. When?

Please list up to 2 (bio)statistics courses you have taken or are taking:

1. When?

2. When?

Please indicate your familiarity with these software packages (0=none, 1=minimal, 2=basic, 3=skilled):

- - spreadsheet (e.g., MS Excel, Lotus) SAS: STATA:

Please tell us something about your research, public health, or other career interests (just a few lines):

Thanks very much for filling out this form, and welcome to EPID 168. Back to EPID 168 home page

9/17/1999 participants.htm