Last 6 digits of phone number: (this will be your pass next time you visit)

Gender: Male Female

What is your age?

What is your racial background?

American Indian or Alaska Native Under-represented Asian subgroup* Asian (not under-represented) Black or African American

Hispanic or Latino Native Hawaiian/Other Pacific Islander White or Caucasian Other (please specify)

*Refers to any Asian other than Chinese, Fillipino, Japanese, Korean, or Asian Indian

In what city/county/state do you work or practice:

City: or County:

Select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Do you work in any of the following places?
(check all that apply)

Please indicate the highest level of education completed:

High School Some College College Graduate

Some Graduate Training Graduate Degree Other:

What degrees/certifications do you currently hold? (check all that apply)
**Note: Do not select more than 5. If more than 5 the last values will be trimmed

	BA		MD
	BS		M.Div
	BSN		Ph.D
	BSW		Ed.D
	RN		DSW
	CNP		D.N.Sc/ND
	MA		D.Pharm
	MS		D.Min
	MSN		DDS
	MSW		PsyD
	M.Ed		Other
	MPH

If other, please specify - If more than one, please put " ; " (semicolon) between each.

Have you ever received any formal training in gerontology or geriatrics? Yes No

If yes, please mark all that apply:
Select multiple by holding "Control","Alt", "Apple", or Command key while clicking your mouse.

Attended Conferences, Workshops, or other Continuing Education Programs in Geriatrics/Gerontology Completed some individual courses in Geriatrics/Gertontology Completed requirements for a Minor in Geriatrics/Gerontology Completed Bachelor's Degree in Gerontology Obtained graduate certificate in aging studies Completed a Master's Degree in Gerontology Pass and ANA/AMA Gerontological/Geriatrics certifcation exam Other

If other, please specify - If more than one, please put " ; " (semicolon) between each.

Please pick the category that best describes your discipline/profession (check one)

If you hold a job, what is your primary place of employment? (check one)

Ambulatory Care/Outpatient Clinic Government Group Medical Practice Home Care Hospice

Hospital Individual Medical Practice Medical School Nursing Home Assisted Living/CCRC

School of Public Health School of Social Work Other Health Professions Schools Other, please specify

What is your Position/Job Title:

What activites do you perform in your work?
(Check One: Your Primary Role)

	Direct Care/Practitioner		Board or Committee Membership
	Counseling		Technical Duties
	Academic Teaching		Administration
	Clinical Teaching		Curriculum Development
	Research		In-Service Training
	Publications		Continuing Education
	Grant-Writing for Research		Community Work
	Grant-Writing for Training & Education		Other
		If other, specify:

Does your place of work emphasize service to any of the following groups?

Yes	No	Older Adults
Yes	No	Geographically Isolated People
Yes	No	Economically Disadvantaged Groups
Yes	No	Minority Populations