1. Name:    First:     Last:

2. Place of Employment: 

3. Position / Job Title:

4. E-mail: 

5. Age (years):

6. Gender:  M     F

7. Racial / Ethnic Background:
American Indian or Alaska Native
Black or African American
Native Hawaiian / Other Pacific Islander
Asian (Specify: e.g., Chinese, Thai, Korean, Filipino)
Hispanic / Latino
White or Caucasian
7a. Other:  (specify) 

8. Do you consider yourself to be presently economically or educationally disadvantaged?
Yes      No

9. Most advanced degree:  -- Select one -- Associate Degree (AA) Associate Degree (AAS) BA BS BSN BSW MA MBA MEd MS MSN MSW PhD EdD ScD MD DO JD

10. What is Your Primary Role? -- Select One -- Administrator/Manager Academic Faculty Clinical Faculty Health Care Practitioner Inservice / Continuing Education Coordinator Student (medical resident, fellow, etc.) Retired or Family Caregiver Other (specify below):
10a. Other Primary Role (not listed): 

11. Which of the following activities do you perform in your current position? (check all that apply):
Continuing Education/Inservice Presentations	Training and Education Grants
Curriculum Development	Publications
Teaching Academic Courses	Serve as a Board/Committee Member
Research Grants	Direct Care Provider

12. What is your Primary Care Discipline?
Select category that best describes your discipline / profession Family Medicine General Internal Medicine Physician Assistant Nurse Practitioner Nurse - Midwife Dentistry Podiatry Other Primary Care (Specify below):
12a. Other Primary Care Discipline (not listed):

13. Other Health Professions (support Primary Care):
Select category that best describes your discipline / profession Allopathic Medicine Osteopathic Medicine Other Advanced Practice Nurse (MSN) Undergraduate Nurse (RN/Diploma, BSN) Chiropractic Dental Public Health Health Administration Public Health Pharmacy Clinical Psychology Social Work Counseling Other Health Profession (specify below):
13a. Other Health Professions (not listed above):

14. Allied Health Discipline (if applicable):
Select the category that best describes your discipline / profession Clinical Laboratory Sciences (Lab Tech) Food and Nutrition Services (DIT or Technician) Health Information (Med. Records / Transcripts) Rehabilitation (Therapist or Assistant in NOT, PT, Recreation / Activities, Speech / Audiology) Dental Hygienist / Dental Assistant Other Technician (EEG, EKG, EMT) Assistants (CNAs, STNAs, Home Health Aides, Medical Assistants) Other Allied Health Discipline (specify below):
14a. Other Allied Health Discipline - Specify:

15. Discipline/Profession Not Related to Health Care
Law (Attorney, Paralegal)
Law Enforcement/Security/Protective Services
15a. Other - Specify:  

16. Are you any of the following?:
Undergraduate Student
Resident
Other Trainee
Practitioner

If you are a health care practitioner and spend at least 50% of your time serving underserved populations (e.g., low income / low socioeconomic status, limited access to care, geographically isolated, etc.), please answer the following two questions:

17. In what type of service site do you work:
Community Health Center	Public Housing Primary Care Center
Migrant Health Center	Mental Health Center
HPSA	State or Local Health Department
Rural Health Clinic	Federally-Qualified Health Center
Indian Health Service	National Health Service Corps Site
Health Care for Homeless Center	State Designated Ambulatory Practice Site
17a. Other service - Specify:

18. Profile of the Population You Serve:

a. Approximate number of older adults served per month:
b. What percentage are racial/ethnic minority elders?
c. What percentage are disadvantaged/underserved elders (e.g., low income/low socioeconomic status, limited access to care, geographically isolated, etc.)?
d. What is the largest minority or underserved elderly population you serve? (e.g., African American, Hispanic, Asian, white, low income/low socioeconomic status, etc.)