New IDEAS: Dementia Specialist Site Feasibility Questionnaire

Principal Investigator Profile

Please provide the following details about yourself and your site:

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* 1. Principal Investigator Name

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* 2. Institution/Practice Name

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* 3. Physical Address of Practice

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address of Principal Investigator

Phone Number

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* 4. Nature of Practice

Solo Physician Practice

Group Practice

University-based department

Hospital-based Department

Other (please specify)

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* 5. Did your practice participate in the original IDEAS Study?

Yes

No

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* 6. Is the Principal Investigator board-certified? If yes, please indicate in which subspecialty. (check all that apply)

No

Yes (select applicable certifications below)

Neurology

Psychiatry

Geriatric Medicine

Other (please specify)

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* 7. Principal Investigator's clinical experience in dementia care (years)

Less than 3 years

3-6 years

7-10 years

11+ years

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* 8. Principal Investigator's clinical research experience as a PI (years)

Less than 3 years

3-6 years

7-10 years

11+ years

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* 9. Does the Principal Investigator currently have Human Subjects Protection (HSP) training through a certification program such as CITI?

Yes

No