Geriatric Consult Service Curriculum Demographic Form

Please take 30 seconds to answer the following questions. They will be used only for grant reporting purposes in the aggregate. All information you provide is kept confidential. Thank you.

Where do you work?

State:

County:

Age and Gender

Age:

Male Female

Race (check all that apply):

Native Hawaiian/Pacific Islander
White
Other

American Indian/Alaskan Native
Asian
Black or African American

If other, please specify:

Are you Hispanic/Latino?

Yes
No

What is your primary role?

Primary Role:

Specify Other:

Discipline

Discipline:

Specify Other:

Most advanced degree earned:

Degree:

Specify Other:

Please indicate the clinical site(s) in which you work.

Check all that apply. For each location you check, please indicate the number of patient encounters you have in an average day:

#: Ambulatory Care Center
#: Assisted Living
#: Chronic/Acute Hospital
Other

#: Home Care
#: Hospice
#: Nursing Home

#: If other, please specify:

Not Applicable