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Name of Training or Event:
Date of Training or Event:
20 years old or younger
40-49 years old
21-29 years old
50-59 years old
30-39 years old
60 years old or older
American Indian/Alaskan Native
More than one race
Prefer not to answer
Native Hawaiian or Pacific Islander
Profession (If student, please indicate your discipline and academic year):
What is your work setting:
Do you work in a Medically Underserved Community? *Medically Underserved Areas/Populations are areas or populations designated by HRSA as having too few primary care providers, high infant mortality, high poverty or a high elderly population.
Do you consider yourself to have every come from a disadvantaged background? Means an individual who (1) Comes from an environment that has inhibited the individual from obtaining the knowledge, skills & abilities required to enroll in & graduate from a health professions school, or from a program providing education or training in allied health professions; (2) comes from a family with annual income below a level based on low income thresholds according to family size published by the US Bureau of the Census.
In which of the following areas did you grow up? (The area in which you spent the most time before age 18.)
Has this training increased your knowledge of Geriatric Medicine and Assessment?
Has this training increased your skill set?
Do you intend to practice what you learned?
General comments on Training or Event:
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