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Title (Mr, Mrs, Dr, Prof, etc.): |
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First Name:
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Middle Name:
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Last Name:
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Suffix (MD, DDS, PHD, MSW, etc.): |
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Primary Email Address (you must be able to access this email account to reset your password):
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Confirm Primary Email Address: |
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Secondary Email Address:
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Confirm Secondary Email Address:
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County of Residence:
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County of Employment:
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Gender:
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Race:
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Ethnicity:
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How did you hear about this course?:
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Other
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Are you currently licensed or will you be applying for a license within the next 6 months through one of the following Pennsylvania boards?
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Are you an Educator seeking Act 126 and/or Act 48 credit? |
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Are you affiliated with a district that submits your Act 48 credits to the PA Dept of Education? |
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Professional Personnel ID (PPID): |
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The following questions are included to help us better understand what currently motivates individuals to file reports with Childline. This information will be collected anonymously for statewide data gathering purposes only and your answers will not be directly connected to your registration or lead to follow-up with you individually. |
Have you ever made a report of child abuse or neglect before?
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Have you ever made a report to Childline when you did not suspect child abuse or neglect?
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Please select the reason(s) why you made a report to Childline when you did not suspect the child to be a victim of abuse or neglect. Select all that apply.
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Please describe the reason you made a report to Childline when you did not suspect the child to be a victim of abuse or neglect
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