Work Authorization
Do you have permanent authorization to work in the United States?
*
Yes
No
Do You Require Visa Sponsorship?
Will you require visa sponsorship now or in the future?
*
Yes
No
Voluntary Self Identification
We invite you to complete this optional survey to help us evaluate our diversity and inclusion efforts. Submission of the information on this form is strictly voluntary and refusal to provide it will not subject you to any adverse treatment or affect your job application. Information obtained will be kept separate from your name or job application. This information will be kept secure and confidential and will be used solely to evaluate our diversity and inclusion efforts.
Please choose your race/ethnicity. Select all that apply
*
White / Caucasian
Hispanic, Latina/o, or Spanish origin
Black or African American
Asian
Native Hawaiian or other Pacific Islander
Indigenous Peoples, First Nations, Native American, or Alaska Native
Middle Eastern or North African
I choose not to disclose
Which gender identities do you most closely identify with?
*
Agender
Genderfluid
Genderqueer
Man
Woman
Non-binary
Something else
I choose not to disclose
Are you a veteran/have you served in the military?
*
Yes
No
I choose not to disclose
Do you have a disability?
*
Yes
No
I choose not to disclose
Do you have an active Physical Therapy license?
*
Yes
No
In which state(s) do you currently hold a Physical Therapy license?
*
How many years of physical therapy experience do you have?
*
How many years of pelvic health experience do you have?
*
If you do not have licensed pelvic health experience, have you had any of the following clinical education experiences in pelvic health? (Mark all that apply.)
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Performing internal vaginal examination and treatment
Performing internal anorectal examination and treatment
Performing external pelvic examination and treatment
None of these experiences, or N/A (I have licensed experience)
As a licensed physical therapist, which of the following settings do you have experience in? (Mark all that apply.)
*
N/A – no licensed experience
Outpatient orthopedic
Outpatient neurological / geriatric
Outpatient pediatric
Outpatient pregnancy / postpartum
Inpatient acute or rehabilitation
Other
Which of the following lab-based (hands-on practice) continuing education and training courses have you completed?
*
None
Internal vaginal pelvic floor examination and treatment
Internal anorectal pelvic floor examination and treatment
Urogynecologic-focused for female pelvic health (beyond a “level 1” course)
Penile/scrotum-focused for male pelvic health
Bowel-focused courses
Pelvic pain-focused courses
Pregnancy rehabilitation
Postpartum rehabilitation
Other / advanced courses
If you have licensed pelvic physical therapy experience, which of the following conditions do you feel confident in treating?
*
Urinary conditions in women
Urinary conditions in men
Bowel conditions in women
Bowel conditions in men
Pelvic pain conditions in women
Pelvic pain conditions in men
Pregnancy and postpartum musculoskeletal conditions
Pediatric pelvic health conditions
None of these
Other
Yes, Pelvic Health Solutions can contact me about job opportunities.
I may receive phone/text communications about career opportunities, interviews, job offers, and other related information from Pelvic Health Solutions (+1 (561) 485-1781) (Message and data rates may apply, message frequency varies). I may receive emails from phsfl.com. I can opt-out at any time by unsubscribing or texting STOP. My data will be handled in accordance with
the privacy policy
and
Terms of Service
. For help, email
support@loxo.co
.
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