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First Name:		Middle Initial:
Last Name:
Address:
City:
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Alternate Number:
E-Mail Address:

Experience/Education:

Please fill out the form below and complete all fields. If you are unsure of an answer, state that you do not know.

I attended a Medical Transcription training program.

Date Course Completed:

I am a Certified Medical Transcriptionist.

I am familiar with the following software products (check all that apply):  DOS  Windows  Microsoft Word/Office  WordPerfect  TransNet  Medrite  Other

I have experience with the following specialty/work type (check all that apply):  Audiology/Speech Therapy  Cardiology/Cardiovascular Surgery  Dermatology  ENT/Otolaryngology  Family Practice  Hematology/Oncology  Internal Medicine  Neurology/Neurosurgery  OB/GYN  Ophthalmology  Orthopedics  Pathology  Plastic Surgery  Psychiatry/Psychology  Pulmonology  Radiology/Nuclear Medicine  Urology  Emergency Medicine  ESL Physicians  Correspondence  Progress/Clinic Notes  Discharge Summaries  Consultation Reports  Operative Reports  History & Physicals  Other

I have been a transcriptionist for:  Less than one year  One to three years  Three to five years  Five to seven years  Seven to ten years  Ten years or more

Commitment

Full-Time (12,000 lines per pay period)

Part-Time (6,000 lines per pay period)

I prefer to work (check all that apply):  Days  Evenings  Split-Shift  Weekdays  Weekends

General Information

What type of internet connection do you currently have?  Dialup  Cable  DSL  ISDN
Preferred specialty?
Preferred work type?
What specialty is most difficult for you?
What work type is most difficult for you?
How many lines do you transcribe per hour?
How many many minutes can you transcribe daily?
If you do not know how many lines you transcribe per hour or how many minutes per day, please provide us with the number of lines you can transcribe in an 8-hour period. Example: 1500 65 character lines per day or 1500 gross lines per day.
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