Annual Meeting 2021 - Saturday Evaluation Contact Information Question Title * 1. Please provide your contact information. Name: * Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address (Certificates sent via e-mail): Phone Number: Question Title * 2. Are you a: Physician (on Medical Staff) Fellow Resident CNP/RN Other (please specify) Question Title * 3. Specialty: Primary Care Medical Sub-specialty Surgeon Other (please specify) Question Title * 4. How may providers are in your practice? 1 2-5 6-10 11-15 >16 Question Title * 5. Please describe the community in which your primary practice/position is located. Urban, inner city Urban, non-inner city Suburban Rural Question Title * 6. Which languages are most represented in your practice? (Check all that apply) English Spanish Portuguese French Mandarin Arabic Somali Nepali Prefer not to answer Other (please specify) Question Title * 7. What racial or cultural group(s) describe your patient population? Select all that apply. White, non-Hispanic/Latino Hispanic/Latino Black/African American Asian Native Hawaiian/other Pacific Islander American Indian/Alaska Native Other (please specify) Question Title * 8. Please indicate your primary employment setting, that is, the setting where you spend most of your time. Self-employed solo practice Two physician practice Pediatric group practice, 3-10 pediatricians Pediatric group practice, >10 pediatricians Multispecialty group practice with primary care only Multispecialty group practice with specialty care only Multispecialty group practice with primary and specialty care Health Maintenance Organization (staff model) Medical School or parent university Non-government hospital/clinic Non-profit community health center City/county/state government hospital or clinic US government hospital or clinic Other (please specify) Question Title * 9. What is your gender? Male Female Prefer not to answer Prefer to self describe Question Title * 10. What is your age? < 31 years 31 - 40 years 41 - 50 years 51 - 60 years > 60 years Question Title * 11. How long have you been practicing medicine? 0 - 5 years 6 - 10 years 11 - 15 years 16 - 20 years > 20 years Question Title * 12. Which languages are you capable of speaking fluently? (Check all that apply) English Spanish Portuguese French Mandarin Arabic Somali Nepali Prefer not to answer Other (please specify) Question Title * 13. With what racial or cultural group(s) do you identify yourself? Select all that apply. White, non-Hispanic/Latino Hispanic/Latino Black/African American Asian Native Hawaiian/other Pacific Islander American Indian/Alaska Native Other (please specify) Question Title * 14. Which of the following best represents how you think of yourself? Straight/Heterosexual Gay Lesbian Bisexual Queer Fluid Other (please specify) Question Title * 15. How did you hear about the meeting? (Check all that apply) Email Blast Ohio AAP Today Ohio Pediatrics Ohio AAP Website Personal Referral/Colleague Postcard in Mail Other (please specify) Question Title * 16. What made you register for the meeting? (Check all that apply) Interesting Topics Need for MOC Part II Credit Networking with Colleagues Adolescent Panel Presentation Keynote Luncheon Presentation Participation in MOC Part IV Program Launch Other (please specify) Question Title * 17. For Non-physicians: Would you like a certificate of attendance? Yes No Next