RETAIN-CT Provider Registration First Name Last Name GenderChoose oneFemaleMaleEmail Address Primary Clinical SettingChoose oneHospitalOutpatient ClinicCommunity Health FacilityEmergency RoomDegree (choose all that apply) MD DC DO RN APRN PT PA Other Degree Other Degree Area of SpecialtyChoose oneOccupational MedicineMental HealthOrthopedicsPain ManagementPhysical Medicine and RehabilitationNeurosurgeonInternal MedicineFamily PracticeChiropraticOtherOther Specialty Name of Practice, Clinic, or Facility Street Address City/Town State Zip Code Years of Clinical Experience Years of clinical experience managing work absence/disability due to musculoskeletal disorders. How confident are you to apply best practices for managing musculoskeletal disorders, including back pain?Choose oneNot ConfidentSomewhat ConfidentConfidentVery ConfidentHow confident are you to manage return to work for musculoskeletal disorders, including back pain?Choose oneNot ConfidentSomewhat ConfidentConfidentVery ConfidentHow did you hear about RETAIN-CT?Choose oneLetter/FaxEmail InvitationColleague RecommendationOtherOther Please provide contact's name below for the member of your office staff (typically the practice manager) who would help you coordinate RETAIN-CT services and contacts with return-to-work coordinators. Please provide contact's title. Please provide contact's phone number. Please provide contact's email adress. CAPTCHACommentsThis field is for validation purposes and should be left unchanged.