Iowa Geriatric Education Center Iowa Geriatric Education Center

Train-the-Preceptor Program in Functional Assessment
User Characteristics

Please take a moment to answer the following questions, as required for our Health Resources and Services Administration (HRSA) funding. They will be used only for grant reporting purposes in the aggregate.
All information you provide is kept confidential. Thank you.

Background: Which of the following best describes you?

Most advanced degree earned?

Are you from an economically disadvantaged background?
(Are you from a low-income family?)


Are you from an educationally disadvantaged background?
(Did your high school have low graduation rates or test scores?)


In which of the following areas did you grow up?
(The area in which you spent the most time before age 18)



Health profession type:
Work/Training:

Where do you work or train?


If working or training outside the U.S., select country:


Do you work or train in a rural setting?


Do you work or train in a Medically Underserved Community (MUC)?


Do you work or train in a Health Professional Shortage Area (HPSA)?


Select your primary work/training location:

Indicate the # of older adults you see in an average day (enter 0 if none):
Age, gender, and race:

Age:

Gender:    


Race (check all that apply):











Are you Hispanic/Latino?

Survey: Is this the FIRST time that you have used this product since July 1st, 2013?