*1.Name(Required.)

First Name

Last Name

*2.Are you an AHRA or RBMA member?(Required.)

I'm an AHRA member

I'm an RMBA member

I'm a member of both AHRA and RBMA

I'm not a member of either AHRA or RBMA

*3.Please identify your primary role in your organization? (select one)(Required.)

Administrative Staff (VP, Administrative Director, Director etc.)

Interpreting Physician / Practitioner

Practice Manager

Imaging Manager

Imaging Technologist

Imaging Safety Officer / Radiation Safety Officer

Medical Director / Clinical Director

Scanning Assistant

Other (please specify)

*4.Organization Name (enter your employer or the organization you represent)(Required.)

*5.Enter Organization City/State (if your organization is in multiple locations, enter the state or region you are based in)(Required.)

*6.What is your organizational structure? (select one)(Required.)

Academic or University Setting

Research

Community

Critical Access

Free Standing/IDTF

Private Physician Office

Other (please specify)

*7.Does your site CURRENTLY utilize Remote Scanning?(Required.)

Yes

No