Nurse Practitioner Program


	Faculty

	Academics

	OUCN

	Courses

	Essentials
	Essentials
	Distance Education

	Use of Technology

	Applications

	Process

	NP Web Resources

	Alumni

Update My Information:

Note:
Since we are using this information to update our records, your personal information will not be sold or distributed to any outside organization or mailing list. However, you should know that this Website does not use a security protocol; so your information will not be protected.

If you do not feel comfortable about submitting this information via the Internet, then please print off the form and do one of the following:

Phone the information to Amy Johnson at 405-271-2163 or 1-877-367-6876
Mail the form to the following address:
The University of Oklahoma
Health Sciences Center,
College of Nursing,
Nurse Practitioner Program,
CNB 324
P.O. Box 26901
Oklahoma City, OK 73126
FAX the form to (405) 271-2321

Fields with an asterisk ( * ) are required.

* First Name:

* Last Name:

* Home Address:

* City:

* State:

* Zip Code:

Home Phone: (xxx-xxx-xxxx)

Mobile Phone: (xxx-xxx-xxxx)

Fax: (xxx-xxx-xxxx)

E-mail:

Clinic or Agency name:

Work Address:

City:

State:

Zip Code:

Work Phone: Ext:

Fax:

Work E-mail:

Year Graduated: (i.e. 2003)

Specialty:

Type of Practice Setting (select all that apply)

Community/Public Health Clinic
Hospital/Hospital Clinic
School/College Health Service
Occupational/Business Health Setting
Correctional Health Services
Physician Office
Residential Care (Nursing home, assisted living, etc)
Home Health Care
College/University (teaching)

Other, please specify:

Designation of Practice Setting (select all that apply)

Indian/Tribal Health Service
Veterans Administration
Rural Health Clinic
Federally Qualified Community Health Center
Armed Services
State, County or City Health Department
Health Personnel Shortage Area (HPSA)
Medically Underserved Area/Community
Migrant Health Center
Homeless Health Center
None of the Above
Unknown

Comments:

Every effort will be made to update the information contained on these pages as necessary. However, it is the responsibility of the user to determine that he or she is relying on the most current version of any particular information. Any questions about the material should be directed to the referenced office or department. Materials and Copyright for work relating to this site belong to The University of Oklahoma Health Sciences Center.