ARAAP 2023 Conference CME/MOC Form

1. Demographic Information

Thank you for taking the time to complete the CME evaluation survey and MOC quizzes.

Your responses will be recorded by the Arkansas Chapter of the American Academy of Pediatrics (ARAAP) and ARAAP Chapter Staff. Please direct any questions about this evaluation to Katie Clark, Project Manager, at katie@arkansasaap.org.

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* 1. First and Last Name

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* 2. Email

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* 3. Birthday, month and year (needed for MOC Part 2 credits)

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* 4. Are you a member of the Arkansas Chapter of the American Academy of Pediatrics?

Yes

Unsure

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* 5. Are you a member of the National American Academy of Pediatrics?

Yes

Unsure

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* 6. If yes, please provide your American Academy of Pediatrics ID number.

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* 7. Please provide your American Board of Pediatrics ID number.

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* 8. Are you a member of the National Association of Pediatric Nurse Practitioners?

Yes

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* 9. Which of the following best describes your training (select best option):

Physician (MD, DO) - Resident/Fellow

Physician (MD, DO) - Early Career

Physician (MD, DO) - Retired

Physician (MD, DO) - Primary Care

Physician (MD, DO) - Subspecialist

Physician (MD, DO) - Pediatric Surgeon

Physician (MD, DO) - Hospitalist/Neonatologist

Nurse Practitioner

Physician Assistant

Registered Nurse

Medical Assistant

Public Health Professional

Healthcare Administrator

Social Services and Other Counseling

Licensed Practical Nurse

Non-Clinical Support Staff

Other (please specify)

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* 10. Which of the following best describes where you work:

Independent primary care practice

Multi-specialty group practice

Hospital-affiliated practice

Urgent care facility

Federally Qualified Health Center

Hospital - Acute care or academic medical center

Hospital - Critical access

Hospital - Long-term acute care hospital or inpatient rehabilitation facility

Health Department - State

Health Department - Territorial

Health Department - Local

Not-for-profit organization

Home health

K-12 school

Other (please specify)

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* 11. Please indicate your professional setting:

Rural (less than 9,999 residents)

Suburban (between 10,000 and 49,999 residents)

Urban, not inner city (50,000 or more residents)

Urban, inner city (50,000 or more residents)