AGEC Participant Profile v.02, 10-19-16, rev.061417

Arkansas Geriatric Education Collaborative

Thank you for attending this program. Please take a few minutes to complete this form. Information requested is required by our funding source, the Health Resources and Services Administration (HRSA). The information you provide will be kept strictly confidential and only reported as aggregate data.

Question Title

* 1. Participant Information

Name

Professional Suffix (e.g. M.D., PharmD, RN, LPN, etc.)

Address

City/Town

ZIP/Postal Code

Email Address

Question Title

* 2. Program Type (Please select from list below)

Video Teleconference

Co-sponsored Regional Program

Alzheimer’s and Dementia Training

APRN Pharmacology Conference

Summer Institute

Geriatric Grand Rounds

Geriatric Long-term care Conference

Family Caregiver Workshop

Other (please specify)

Question Title

* 3. Event Details

Title

Date

Location Where Attending

Question Title

* 4. Are you a student?

Yes

IF STUDENT, please identify discipline (e.g., Nursing, Pharmacy, etc.)

Question Title

* 5. Gender

Male

Female

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* 6. What is your age group?

19 and under

20-29 years old

30-39 years old

40-49 years old

50-59 years old

60 and older

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* 7. Ethnic Classification

Hispanic or Latino

Non-Hispanic/Non-Latino

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* 8. Race (choose one)

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Pacific Islander

White

More than one race

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* 9. Background

	Yes	No
a) Do you consider yourself to have EVER come from a disadvantaged background?	a) Do you consider yourself to have EVER come from a disadvantaged background? Yes	a) Do you consider yourself to have EVER come from a disadvantaged background? No
b) Do you work in a rural setting?	b) Do you work in a rural setting? Yes	b) Do you work in a rural setting? No
c) Do you work in an urban setting?	c) Do you work in an urban setting? Yes	c) Do you work in an urban setting? No
d) Do you work in a Medically Underserved Community (MUC)?	d) Do you work in a Medically Underserved Community (MUC)? Yes	d) Do you work in a Medically Underserved Community (MUC)? No
e) Are you an underrepresented Minority?	e) Are you an underrepresented Minority? Yes	e) Are you an underrepresented Minority? No

Question Title

* 10. If you answered YES to question 9e (an underrepresented Minority), choose which of the following...

African American/Black

American Indian or Alaska Native

Hispanic (all races)

Native Hawaiian or Other Pacific Islander

Question Title

* 11. Profession/Occupation (Please select ALL that apply)

Advanced Practice Nurse(APRN/APN)

Audiologist

Certified Health Education Specialist (CHES)

Certified Registered Nurse Anesthetist (CRNs)

Certified Nurse Midwife (CNM)

Certified Nurse Practitioner (CNP)

Clinical Nurse Specialist (CNS)

Clinical Psychologist

Community Member

Direct Care Worker (DCW or CNA)

Doctorate of Nursing Practice (DNP)

Doctor of Osteopathy (DO)

Emergency Medical Services (EMS)

Family Caregiver

Firefighter

First Responder - Alzheimer's Disease and Dementia Training

Health Educator

Kinesiotherapist

Law Enforcement Officer

Licensed Practical Nurse (LPN)

Licensed Psychiatric Technician (LPTN)

Licensed Vocational Nurse(LVN)

Long Term Care Administrator/Nursing Home Administrator

Medical Doctor (MD)

Occupational Therapist (OT)

PharmD

Physical Therapist (PT)

Physician Assistant (PA)

Registered Dietitian (RD)

Registered Nurse (RN)

Registered Nurse Practitioner (RNP, NP)

Respiratory Therapist (RT)

Social Worker (LSW, LMSW, LCSW)

Speech Pathologist

Veteran

Other (please specify)