SHEPS CENTER DATA REQUEST FORM
NC Health Professions Data
Podiatrist Data
Fill out this form, print, and fax it to:
The Board of Podiatry Examiners of the State of North Carolina
1500 Sunday Drive, Suite 102
Raleigh, NC 27607
David Feild, Executive Secretary
(919) 787-5181
FAX (919) 787-4916

Attach a separate page describing the intended use for the labels/listing. Once approval has been received by the Sheps Center, you will be contacted with an estimated price and delivery date of the output. Contact the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 if you have questions or need additional information.

Requester's Name:
Business Name:
Address:
City, State & ZIP:
Telephone Number:
Fax Number:
Email Address:
Type of Organization: For-Profit (FP)     Non-Profit (NP)

Electronic Output Request Type: Check one or more
Name, address, specialty, county ($4.50/100 names: $100.00(NP)/$200(FP) minimum)
All data available ($7.00/100 names: $200.00(NP)/$300(FP) minimum)

Output format:
 Tab-delimited Comma-delimited Fixed Field
Other (please specify):

SELECTION CRITERIA (check all that apply):

Activity Status: Active   Inactive

Area Selection: In-state   Out-of-state
Specific counties:
Other (please specify)

Practice Setting:
Unknown
Hospital - Non-federal
Nursing Home - Non-federal
Clinic - Non-federal
Practice Office - Non-federal
Other - Non-federal
Federal Health - Military
VA, Public Health, Indian Health (Federal)
Other Federal
School, Education
Other type

Form of Employment:
Unknown
Solo - Self-Employed
Non-solo - Self-Employed
Individual Practitioner
Partnership or Group
County Government
State Government
Federal Government
Other

Primary Specialty:
Unknown    No Specialty    Foot Orthopedics/Biomechanics    General Practice
Podogeriatrics    Surgery

Description of Request: List other details of your request in the box below.


What order do you want the output sorted in?

NOTICE: Data are provided by the Board of Podiatry Examiners of the State of North Carolina as of October each year and compiled by the Sheps Center. Address changes are made only at the time of the annual update. Contact the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 for more detailed information regarding the Sheps Center files.

For Board of Podiatry Examiners of the State of North Carolina Use Only:
Approved by:______________________________________________  Date:________

Note to Board: Please send this form with approval to the Sheps Center Data Coordinator:
Fax (919) 966-5764.

Updated 5/1/05