Thank you for your interest in the National Center for Equitable Care for Elders' Addressing Social Determinants of Health Through Community-Based Palliative Care Learning Collaborative. This learning collaborative will discuss care management for older adults with a serious illness and the importance of identifying gaps in non-clinical services and support for those patients and their caregivers. This learning collaborative will be held on April 12, April 26, May 10, and May 24 from 1:00-2:00 PM ET. 

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* 1. What is your first and last name?

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* 2. What is your email address?

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* 3. If you'll be calling in during each learning collaborative session, what phone number will you be using?

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* 4. What is the name of your organization? (Note: Our training and technical assistance is intended for HRSA-funded health center and health center program look-alike personnel. If you are unsure if your organization is a HRSA-funded health center or look-alike, you can check out HRSA's Find a Health Center resource for clarification.)

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* 5. What is your position? 

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* 6. Supervisor Name 

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* 7. Supervisor Email
(Note: Supervisors will be contacted and asked to acknowledge their support for your participation in this activity.)

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* 8. How did you hear about this learning collaborative?

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* 9. Why did you register for this learning collaborative?

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* 10. What do you plan to do with the information you learn from this learning collaborative?

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* 11. How ready are you to implement the information from this learning collaborative at your health center?

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* 12. What percentage of your health center's patient population are older adults aged 65 and older?

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