The information collected will be used by the LIGEC for research, program design, and reporting purposes. No information will be reported individually or attributed to individuals and names of individuals will not be used. The Long Island Geriatric Education Center has been asked to provide specific information about the associates to its funding source, the Federal Bureau of Health Professions. The information you provide is confidential. This data is extremely important and will be used to help secure continued funding for the center. Federal funding guidelines require that these questions be asked of attendees, but you are not required to answer every question in order to attend the course. We would greatly appreciate your help in providing the following:
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Personal Information |
Gender |
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Male
Female
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| Age |
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18-29
30-39
40-49
50-59
60 or older
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| Racial/Ethnic Background |
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| If you selected other for your Racial/Ethnic Background, please specify |
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Educational Background |
Most Advanced Degree |
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| Please specify your degree as mentioned above |
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| If MD/DO, do you have a CAQ in Geriatrics? |
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Yes
No
Not Applicable
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Discipline (Pick the category that best describes your discipline) |
Dental/Oral Health
Medicine
Nurse Practitioner
Nursing (CNA/LPN/RN)
Licensed Practical Nurse
Occupational Therapy
Physician Assistant
Pharmacy
Physical Therapy
Registered Nurse
Social Work
Other, please specify
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| If you selected Other, please indicate your discipline |
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| Professional Position (check all that apply) |
Full Time Faculty
Adjunct Faculty
Direct Service Health Care Provider
Student
Other
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| Work Site (check all that apply) |
Work on Campus
Work in rural health site
Hospital Pharmacy
Community Pharmacy
Other Pharmacy setting, please specify
Other work site
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| If you selected other for work site, please specify |
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Employment Information |
What is your position/job title?
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| What is your primary role? |
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| Which of the following activities do you perform in your current position? (check all that apply) |
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| If you selected Other in the question above, please specify |
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Profile of the Population You Serve |
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Approximate number of older adults served per month.
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What percentage are racial/ethnic minority elders? %
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What percentage are disadvantaged/underserved elders (eg. low income/low socioeconomic status, limited access to care, geographically isolated, etc.)? %
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| What is the largest minority or underserved elderly population you serve (eg. African American, Hispanic, Asian, white, low income/low socioeconomic status, etc.)? |
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Site of Practice: (please check if you work in any of the following sites) |
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| If you checked Other in the above questions, please specify |
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