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SWTRC Learning Library Demographics
At the completion of this survey you will receive a username and password to access the videos
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1.
Please provide the following
(Required.)
Name:
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Organization:
City/Town:
State:
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AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
Email Address:
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Phone Number:
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2.
What is your role in telehealth/telemedicine (check all that apply)?
(Required.)
Clinical (MD/DO)
Clinical (DDS/DMD)
Clinical (RN/LPN/CNM)
Clinical (RT/PT/OT)
Clinical (PA)
Clinical (PhD)
Program Director
CEO
CFO
CIO
Business Manager
Administrator
Marketing
IT
Network Engineer
Training
Site Coordinator
Technical Coordinator
Education
Quality/Legal & Regulatory
Research
Other (please specify)
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3.
What type of healthcare organization do you work in (check all that apply)
(Required.)
Academic Institution / School
Association / Organization
Area Health Association
Clinic
Free Clinic
Federally Qualified Health Center (FQHC)
Rural Health Clinic (RHC)
Clinical - Private Practice
Clinical - General
Funders (Foundations / Health Plans)
Foundations
Hospital / Health System
Critical Access Hospital (CAH)
Small Hospital Improvement Program (SHIP)
Non-Profit Hospital / Health System
Government Agency
Corrections
Medicaid / Medicare
Public Health
Social Service
State Office of Rural Health (SORH)
Legislator / Policy Maker
Legal
Telehealth Resource Center
Tribal / IHS
Vendor
Vendor - Business Solutions
Vendor - Clinical Service Provider
Vendor - Technology
Vendor - Telecommunications
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4.
Are you a HRSA Grant Funded Entity?
(Required.)
Yes
No
Not Sure
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5.
Where are you located?
(Required.)
Arizona
Colorado
Nevada
New Mexico
Utah
Other
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6.
Does your organization currently utilize telemedicine?
(Required.)
Yes
No
Not Sure
7.
If yes, in what capacity (mark all that apply).
Provides patient referrals
Provide clinical consultations
Administration
Attending continuing education
Technical support
Other (please specify)
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8.
How long has your organization been involved with telehealth/telemedicine?
(Required.)
0 years
1-3 years
4-6 years
7-10 years
11-14 years
15-18 years
19-22 years
>23 years
Not sure
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9.
How long have you been involved in telehealth/telemedicine?
(Required.)
0 years
1-3 years
4-6 years
7-10 years
11-14 years
15-18 years
19-22 years
>23 years
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10.
How many telehealth/telemedicine training events have you attended?
(Required.)
Never
1
2
3
4
5 or more
11.
How did you receive your telehealth/telemedicine training (check all that apply)?
In-person course or session
Telehealth Resource Center On-line course or tutorial
From another On-line course or tutorial
Course at professional meeting
Text book review
CD/DVD course
Other (please specify)