Wufoo

OHSU Community Service Tracker

OHSU students, faculty and employees give back to the community in many ways. Please complete this short survey to let us know about the activity you performed so that we can accurately track this service. Submit one entry per activity.

This mechanism also tracks Student Community Service activities and hours for those OHSU students with a community service requirement.

If you complete this online form for OHSU, we will use the personal identifying information for internal purposes only. We do not share, sell or loan the information to outside parties except as required by law. OHSU assumes no liability for any problems with this site or its content.

Entering your information in this format is optional. You may request a paper form by emailing scied@ohsu.edu. Questions? Contact the Office of Science Education Opportunities at scied@ohsu.edu.

Please note by submitting this form you are agreeing to the Terms of Service, which have been approved by OHSU Legal.

Name * First Last
Email Address *
Your Role at OHSU *
Student Staff Faculty Resident/Fellow Other
If you marked STUDENT or RESIDENT/FELLOW, please include your graduating year.
If you marked OTHER, please tell us what your role is at OHSU.
Your Affiliation at OHSU *
School of Dentistry School of Medicine School of Nursing OHSU/OSU College of Pharmacy Physician Assistant Program Academic & Student Affairs Central Services Hospital & Clinics Other

Select all that apply
If you marked OTHER, please tell us your affiliation at OHSU.
Your Department/Division at OHSU

Please select from the options below.
School of Medicine
School of Dentistry
Research Institutes & Centers
If you participated in this activity as a representative of a Student Interest Group, please indicate which group.
Beginning (or only) Date of This Activity * MM / DD / YYYY
Ending Date of This Activity MM / DD / YYYY
If you are reporting about a regular volunteer commitment, please estimate the hours served during the quarter below.
July 2012 - September 2012 October 2012 - December 2012 January 2013 - March 2013 April 2013 - June 2013 July 2013 - September 2013
How many hours did you dedicate to this activity? *

If you regularly partcipate in this activity (i.e. weekly, monthly), please submit one entry each quarter.
How many people did you serve during this activity? *
School, organization or program you worked with for this activity *
If you marked OTHER, please tell us which school, organization or program you worked with for this activity.
If you did this activity in fulfillment of an OHSU requirement, please indicate the on-site supervisor's name.
If you did this activity in fulfillment of an OHSU requirement, please provide the on-site supervisor's email address or other contact information.
How would you categorize this service activity? *
Advocacy Education Global Health Preventative Healthcare Research Social Justice Other

Select all that apply
If you marked OTHER, please tell us the category of this activity.
What did you do during this activity? *
Would you like to be notified about future volunteer activities?
Yes No
Do Not Fill This Out

Wufoo

Your Department/Division at OHSU