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.
Name: ______
GENDER: Male______Female______
AGE: Under 20_____ 20-29_____ 30-39_____ 40-49_____
50-59_____ 60-69 _____ 70 years or older ______
ZIP CODE OF YOUR PLACE OF EMPLOYMENT: ______
LENGTH OF TRAINING/COURSE: ______hours
Have you attended any other GEC-sponsored programs this year? Yes No
If so, how many have you attended? ______
Are you of Hispanic or Latino ethnicity? YES NO
YOUR RACE and ETHNICITY (check all that apply):
_____ Native American or Alaska native
_____ Underrepresented Asian Subgroup (any
Asian other than Chinese, Filipino, Japanese, Korean, Asian Indian or Thai)
_____ Asian (Not Underrepresented)
_____ Black or African American
_____ Native Hawaiian or other Pacific Islander
_____ White
_____ Unknown
_____ More than one Race
YOUR BACKGROUND
Do you consider yourself to be from an economically or educationally disadvantaged background? YES NO
In what type of area do you currently live? URBAN RURAL SUBURBAN FRONTIER
EMPLOYMENT SETTING OF TRAINEE
Do you work in a medically underserved community? (MUC) YES NO
Do you work in a rural setting? YES NO
Do you work as part of an interdisciplinary team? YES NO
If so, how many people are in your team? ______
LOCATION OF CLINICAL TRAINING/PATIENT ENCOUNTERS
_____ Ambulatory Care Centers
_____ Assisted Living
_____ (Chronic and Acute Disease) Hospitals
_____ Home Care
_____ Hospice
_____ Nursing Homes
_____ Palliative Care
_____ Senior Centers
_____ Senior Housing
_____ Tele-health
YOUR DISCIPLINE
Medical/Dental
Allopathic Medicine physician
Dental hygienist
Dentist
Osteopathic medicine physician
Physician assistant
Podiatrist
Psychiatrist
Other Disciplines
Health administrator
Health education specialist
Health information systems/data analyst
Health professions student
Marriage and family therapist
Medical assistant
Professional counselor
Psychologist
Public health specialist
Social worker
Unknown
Aging Care Manager
Mental Health Case Manager
Other (specify)
Nursing
Certified Nursing assistant
Licensed Practical Nurse
Registered Nurse
Nurse Midwife
Nurse Practitioner
Associated Health Professions
Audiologist
Chiropractor
Community health worker
Epidemiologist
First responder (e.g., EMP, paramedic, fire rescue, HazMat)
Home health aide
Nutritionist
Occupational health specialist
Occupational therapist
Optometrist
Pharmacist
Physical therapist
Speech therapist
Veterinary physician
Thank you very much for your time and effort!
Please leave us your email address if you’re interested in further information about other educational activities with the GEC/PA.
______
Please return this form to:
PA Behavioral Health and Aging Coalition
Fax 717-370-6016