* 1. Name:

* 3. Practice/Organization

* 4. Email:

* 5. Please indicate any NNECOS educational activities in which you have participated in the past:

* 6. Preferred methods to receive education

  Very interested Moderately interested Somewhat interested Not interested
Person to person
Meetings / conferences
Formal courses
Videos
Teleconferences
Internet
Journal club

* 7. Factors that impact the decision to participate in education: (check all that apply)

* 8. Please check up to 10 educational priorities/areas of interest

* 9. What schedule of CE activities are you more likely to attend? (Check all that apply)

* 10. How often do you access NNECOS website?

* 11. Are you aware of the NNECOS speakers list for educational activities?

* 12. Would you like to be contacted by a member of the educational committee for help in setting up a meeting at your institution

* 13. Would you be interested in participating in multi-institutional trials & learning more about potential collaborative research opportunities?

* 14. Please share any additional comments regarding how NNECOS can help meet your educational needs:

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