GEC 14/15 Demographic Form

Geriatric Education Center of Pennsylvania (GEC/PA) Demographic Form 2014/15

Our sponsor is interested in learning who attends our educational programs. Please help us continue to provide these sessions by filling out the demographic information below.

Thank you!

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* 1. First Name

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* 2. Last Name

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* 3. Credentials (eg: RN, DO, MD)

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* 4. Position/Title:

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* 5. Email

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* 6. I identify my gender as

Male

Female

Transgender

I prefer not to disclose

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* 7. Age

Under 20

20 - 29

30 - 39

40 - 49

50 - 59

60 - 69

70 years and older

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* 8. Zip code of your PRIMARY place of employment

ZIP:

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* 9. Have you attended any other GEC-sponsored programs this year?

Yes

Don't Know

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* 10. If yes, how many have you attended?

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* 11. Your race and ethnicity (check all that apply)

Native American or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Unknown

More than one Race

Other (please specify)

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* 12. Are you of Hispanic or Latino ethnicity?

Yes

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* 13. I will apply this training to National Certification or Continuing Education requirements.

Yes

N/A