ATTP Application for Individual Practitioners and Practicing Teams Survey

Application for Grand Rapids, MI April 21-25, 2010

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1. Today's Date (MM/DD/YYYY):

Today's Date (MM/DD/YYYY):

2. I am applying for this training as: (check one)

I am applying for this training as: (check one) Individual practitioner

Attending with work team

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3. Contact Information:(State in name if Ms., Mr., or Dr.)

Contact Information:(State in name if Ms., Mr., or Dr.) Full Name:
Home Address:
Home Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

4. List professional degrees for printed certificate:

List professional degrees for printed certificate:

5. Your current profession: (Select one)

Your current profession: (Select one)

If Medicine or Other (please specify)

6. How did you hear about the ATTP training?(check all that apply)

How did you hear about the ATTP training?(check all that apply) NPF website NPF Parkinson Report ATTP brochure/flyer	Colleges who attended ATTP Professional org. website
Other (please specify)

7. How would you describe yourself?

How would you describe yourself? Asian Black (African American) Native American/American Indian	Native Hawaiian or Other Pacific Islander Black (non-African American) White
Other (please specify)

8. Are you of Hispanic/Latino origin?

Are you of Hispanic/Latino origin? Yes	No
If yes, country of origin:(please specify)

9. Business Information:

Business Information: Name of Primary Work Setting
Street Address:
City:
County:
State:
Zip / Postal Code:
Work Phone:
Work Fax:
Mobile Phone Number:

10. Work Job Title:

Work Job Title:

11. Number of years of experience practicing your profession:

Number of years of experience practicing your profession:

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12. Your license number is required in order to report CMEs/CEUs:
Please provide your license number and the state which it was issued:

Your license number is required in order to report CMEs/CEUs: Please provide your license number and the state which it was issued: State or National License#:
State issued:

EDUCATION:

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13. Undergraduate Education

Undergraduate Education Name of School:
Major and area of specialty, any:
Degree/ Diploma:
Year degree granted:

14. Graduate or Medical Education:

Graduate or Medical Education: Name of School:
Major and area of specialty, if any:
Degree/ Diploma:
Year degree granted:

15. Professional/Other School or Training:

Professional/Other School or Training: Name of School:
Major and area of specialty, if any:
Degree/ Diploma:
Year degree granted:

EXPERIENCE:

16. Brief description of your work experience (include any experience with older adults or persons with Parkinson's disease or care partners) (Max 250 words)

Brief description of your work experience (include any experience with older adults or persons with Parkinson's disease or care partners) (Max 250 words)

17. Have you worked with diverse racial or cultural groups?

Have you worked with diverse racial or cultural groups? Yes	No
If yes (please specify)

18. Are you currently working in medically underserved areas?

Are you currently working in medically underserved areas? Yes

19. Do you have experience with rural populations?

Do you have experience with rural populations? Yes

20. Do you have experience in working on an interdisciplinary team?

Do you have experience in working on an interdisciplinary team? Yes

21. If you are currently on an interdisciplinary team, please answer the questions below:

If you are currently on an interdisciplinary team, please answer the questions below: How long has your current interdisciplinary team been functioning?(#years)
How long have you been on this team?(#years)

22. What issues around interdisciplinary teams are of most interest to you?

What issues around interdisciplinary teams are of most interest to you?

23. Please select one number that indicates your confidence:

	Not at all confident 1	2	3	4	5	6	7	8	9	Extremely confident 10
How confident are you now in working with or treating a person with Parkinson disease?	*Please select one number that indicates your confidence: How confident are you now in working with or treating a person with Parkinson disease? Not at all confident 1	How confident are you now in working with or treating a person with Parkinson disease? 2	How confident are you now in working with or treating a person with Parkinson disease? 3	How confident are you now in working with or treating a person with Parkinson disease? 4	How confident are you now in working with or treating a person with Parkinson disease? 5	How confident are you now in working with or treating a person with Parkinson disease? 6	How confident are you now in working with or treating a person with Parkinson disease? 7	How confident are you now in working with or treating a person with Parkinson disease? 8	How confident are you now in working with or treating a person with Parkinson disease? 9	How confident are you now in working with or treating a person with Parkinson disease? Extremely confident 10
How confident are you now in working with the care partner of a person with Parkinson disease?	How confident are you now in working with the care partner of a person with Parkinson disease? Not at all confident 1	How confident are you now in working with the care partner of a person with Parkinson disease? 2	How confident are you now in working with the care partner of a person with Parkinson disease? 3	How confident are you now in working with the care partner of a person with Parkinson disease? 4	How confident are you now in working with the care partner of a person with Parkinson disease? 5	How confident are you now in working with the care partner of a person with Parkinson disease? 6	How confident are you now in working with the care partner of a person with Parkinson disease? 7	How confident are you now in working with the care partner of a person with Parkinson disease? 8	How confident are you now in working with the care partner of a person with Parkinson disease? 9	How confident are you now in working with the care partner of a person with Parkinson disease? Extremely confident 10

24. What interested you most about this training program? (Max 250 words)

What interested you most about this training program? (Max 250 words)

For more information about the ATTP program, please visit the NPF website (www.parkinson.org/attp).
We encourage to complete this application to better serve you; never the less, if you still need our traditional enrollment application, you may download it, fill it and send it electronically to: attp@parkinson.org or via fax 305-243-8274.
Questions? Contact Denise Beran Tel: 305-243-2985

(You will be notified about your application by email or, if no email provided, by mail)

ACCREDITATION STATEMENTS:

Physicians: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the USF Health and the National Parkinson Foundation. The USF Health is accredited by the ACCME to provide continuing medical education for physicians. The USF Health designates this educational activity for a maximum of 27.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Physician Assistants: This program has been reviewed and is approved for a maximum of 27 hours of AAPA Category I (Pre-approved) CME credit from the Physician Assistant Review Panel. Physician Assistants should claim only those hours actually spent participating in the CME activity. This program was planned in accordance with the AAPA’s CME Standards for Live Programs and for Commercial Support of Live Programs.

Nurses (ANCC): The University of South Florida College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This activity is for 27.5 contact hours.

Physical Therapy: The USF Health is an approved provider of Continuing Education for Physical Therapists pursuant to the Board of Physical Therapy chapter 64b17-9. The USF Health designates this educational activity for up to 33 contact hours.

Florida Licensed Clinical Social Workers: The USF Health is an approved provider (BAP#433 – Exp. 3/31/11) of continuing education credits for clinical social work, marriage and family therapy, and mental health counseling. This program has been reviewed and approved for up to 33, 50-minute contact hours. Non-Florida licensees may use the USF certificate to apply for credit through their state board.

Florida Licensed Occupational Therapists: The USF Health is an approved provider (#107, exp. 2/28/11) of continuing education for Occupational Therapy Licensees. This program has been reviewed and approved for up to 33, 50-minute contact hours. Licensee numbers are required prior to the issuance of certificates. Non-Florida licensees may use the USF certificate to apply for credit through their state board.

Speech-Language Pathologists: The Department of Communication Sciences & Disorders of the University of South Florida is approved by the Continuing Education Board of the American Speech-Language Hearing Association (ASHA) to provide continuing education activities in Speech Language Pathology and Audiology. This program is offered for 2.7 CEUs/ 27 contact hours (intermediate level; professional area) The ASHA CE provider approaval does not imply endorsement of course content, specific products or clinical procedures.

Music Therapists: are given a certificate of attendance from NPF which they submit for recertification for accreditation of continuing education for up to 33, 50-minute contact hours. MT’s will also receive a separate paper of instruction for reporting these hours which can be applied to meet the CBMT course content outline requirements.

ATTP Application for Individual Practitioners and Practicing Teams

*1. Today's Date (MM/DD/YYYY):