EPIC Registration

This form will register you as an EPIC user.

There is no cost associated with registering for this program. If you would like to work towards the Expert Preceptor designation, be sure to click on the appropriate checkbox below.

Filling out this form will take you to the survey page. While we would appreciate your taking the time to complete the survey, it is completely optional. However, you must confirm your registration on the survey page to create a personalized homepage that will allow you to access the EPIC modules, discussion forum, and preceptor profiles. You will also be able to track your progress, and review and print your completed work through your module "notebooks."

Please do not use a password that you use on other secure systems. EPIC security is meant only to informally protect access to these materials.

First name: Last name:

Login name: Password:*

Customarily, your login name consists of your initial and your last name. For example, John Smith's login name would be jsmith. Your login and password may not contain spaces, periods or commas.

Confirm password (type in your password again):

Mother's Maiden Name (for retrieving forgotten password):

*Please write down your login name and your password, since you'll need them when you sign in to EPIC, and they are what we'll use to track your progress.

Address:

Street:

City: State: Zip code:

Phone numbers:

Day: Night:

Email address:

Click in the box below if you would like to work towards the Expert Preceptor designation

Expert Preceptor Designation

Press the Continue button to proceed to the Pre-assessment page.

Press the Clear form button to erase your entries in this form and start again.