Hampton Roads Ultrasound Academy POCUS Class Registration
Complete one request per participant for the Abdominal POCUS class and provide your professional and ultrasound experience details so HRU can confirm your seat and next steps.
Course and participant
Class selection
*
Abdominal POCUS
Venous POCUS
Full legal name
*
First Name
Last Name
Preferred name
Email address
*
example@example.com
Mobile or preferred contact phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
City of residence
*
State/province/region of residence
*
Postal code
Country of residence
*
Please Select
United States
Canada
Mexico
Other
Age range
18-24
25-34
35-44
45-54
55-64
65 or older
Prefer not to answer
Gender
Woman
Man
Nonbinary
Self-described
Prefer not to answer
Please describe your gender
Professional background and licensure
Primary professional role
*
Physician (MD/DO)
Physician assistant (PA)
Nurse practitioner (NP)
Registered nurse (RN)
Licensed practical or vocational nurse (LPN/LVN)
Sonographer or vascular technologist
Other healthcare professional
Healthcare student or trainee
Other
Please describe your professional role
*
Degrees and professional credentials
Primary clinical specialty
*
Family or primary care
Internal medicine or geriatrics
Emergency medicine
Urgent care
Hospital medicine or critical care
Surgery
Obstetrics and gynecology
Cardiology or vascular medicine
Urology or nephrology
Anesthesiology
Other
Not currently in clinical practice
Please describe your clinical specialty
*
Employer, practice, or school name
Primary license or certification type
*
Issuing board or certifying organization
*
Licensing state, country, or jurisdiction
*
License or certification number
*
Expiration or renewal date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional ultrasound certifications
Primary practice or training setting
*
Outpatient office or clinic
Hospital or inpatient service
Emergency department
Urgent care center
Long-term care or assisted living
Mobile or community service
Academic or training program
Other
Not currently practicing
Years in clinical practice
*
Student or not yet practicing
Less than 1 year
1-5 years
6-10 years
11-20 years
More than 20 years
Current professional license or certification status
*
Active
Inactive or expired
Student or trainee without a license
No current license or certification
Previous ultrasound experience
Previous ultrasound experience
*
No prior experience
Observed scans only
Hands-on training without patient scanning
Performed supervised patient scans
Perform independent clinical scans within your professional scope
Previous ultrasound training
School or residency training
Short course or workshop
Online education
Employer-based training
Formal ultrasound program
None
Other
Approximate ultrasound scans personally performed per month
*
0
1-5
6-20
21-50
51 or more
Not sure
Ultrasound applications previously practiced
Abdominal organs
Renal and bladder
Cardiac
Lung
Vascular or DVT
FAST or eFAST
Obstetric or gynecologic
Ultrasound-guided procedures
Other
None
Current confidence obtaining basic abdominal ultrasound images
*
1 No confidence
1
2
3
4
5 Very confident
5
1 is 1 No confidence, 5 is 5 Very confident
Access to an ultrasound system for practice after class
*
Yes
No
Expected within 6 months
Not sure
Main learning goal
Have you previously participated in an HRU Academy class or the Open Scan Lab?
*
No
Yes
Not sure
If yes, which course or activity?
How did you hear about this class?
*
HRU website
Internet search
Email from HRU
Social media
Colleague or word of mouth
Employer or school
Professional association or event
Previous HRU class or Open Scan Lab
Other
If other, please specify
Referring person, organization, or campaign code
What future training topics are you interested in?
Abdominal POCUS
Cardiac POCUS
Vascular or DVT ultrasound
Lung ultrasound
Ultrasound-guided procedures
OB Ultrasound
Open Scan Lab
Private group training
No current interest
Other
Would you like to discuss training for a practice or organization?
Yes
No
Maybe
Registration acknowledgment
Acknowledgment of information accuracy and permitted use
*
I confirm that the information provided is accurate to the best of my knowledge and may be used by HRU for course administration and participant communication. I also understand HRU may summarize enrollment and participant characteristics without names, contact details, or license numbers to evaluate program growth and reach.
Understanding of registration request and separate confirmation
*
I understand that submitting this form is a registration request and that HRU will confirm seat availability and payment arrangements separately.
Typed full name
First Name
Middle Name
Last Name
Acknowledgment date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Registration Request
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