LONG ISLAND GERIATRIC EDUCATION CENTER
ASSOCIATE PROGRAM APPLICATION/PARTICIPANT PROFILE
Fields labeled in red are required.
Title
Mr. Ms. Mrs. Dr.
 
First Name   Middle Name   Last Name  
 
Degree(s)  
 
Academic/Organization Affiliation  
 
E-mail Address  
 
Work Information
Street Address
City State Zip
Phone
Fax
 
Home Information
  Street Address
City State Zip
Phone
 
Preferred Address
Home    Work
 


We need your help! The Long Island Geriatric Education Center has been asked to provide specific information about the associates to its funding source, the Federal Bureau of Health Professions. The information you provide is confidential. This data is extremely important and will be used to help secure continued funding for the center. We would greatly appreciate your help in providing the following:

Personal Information

Gender
Male    Female    Prefer Not To Answer
 
Social Security Number (last 4 digits)
XXX - XX - 
 
Date of Birth **
 
 
 
Racial/Ethnic Background **
 
If you selected other for your Racial/Ethnic Background, please specify **
 
Do you consider yourself to have ever been from an economically or educationally disadvantaged background? **
Yes    No
 
** Optional; Federal funding guidelines require that these questions be asked of attendees.

Educational Background

Most Advanced Degree
 
Please specify your degree as mentioned above
 
If MD/DO, do you have a CAQ in Geriatrics?
Yes    No    Not Applicable

Discipline or Profession

Pick the category that best describes your discipline/profession
 
If you selected Other for the above question, please specify

Employment Information


What is your position/job title?
 
What is your primary role?
 
Which of the following activities do you perform in your current position? (check all that apply)
Continuing Education /Inservice Presentations
Curriculum Development
Teaching Academic Courses
Research Grants
Training and Education Grants
Publications
Serve as a Board/Committee Member
Direct Care Provider
Other, please specify
 
If you selected Other in the question above, please specify

Additional Questions

If you are a health care practitioner and spend at least 50% of your time serving underserved populations (eg., low income/low socioeconomic status, limited access to care, geographically isolated, etc.), please answer the following
 
Site of Practice: (please check if you work in any of the following sites)
Community Health Center
Health Care for Homeless Center
Rural Health Clinic
National Health Service Corps Site
Federally-Qualified Health Center
Ambulatory Practice Sites Designated by State Governers
HPSA (Federally Designated Health Professionals Shortage Area)
Migrant Health Center
Public Housing Primary Care Center
Mental Health Center
Indian Health Service
State or Local Health Department
Other, please specify
 
If you checked Other in the above questions, please specify
 
Profile of the Population You Serve
Approximate number of older adults served per month.  
What percentage are racial/ethnic minority elders?  %
What percentage are disadvantaged/underserved elders (eg. low income/low socioeconomic status, limited access to care, geographically isolated, etc.)?  %
What is the largest minority or underserved elderly population you serve (eg. African American, Hispanic, Asian, white, low income/low socioeconomic status, etc.)?  
 
 
Faculty/Provider Geriatric Education Needs Survey
Completion of the following survey is voluntary. The information collected will be used by the LIGEC for research, program design, and reporting purposes. No information will be reported individually or attributed to individuals and names of indviduals will not be used.
Health Profession

If you selected other, please specify
 
Professional Position (check all that apply)
Full Time Faculty
Adjunct Faculty
Direct Service Health Care Provider
Student
Other
 
Work Site (check all that apply)
Work on Campus
Work in rural health site
Hospital Pharmacy
Community Pharmacy
Other Pharmacy setting, please specify
Other work site
 
If you selected other for work site, please specify
 
Do you teach/precept students?
Yes  No  N/A
 
Do you cover geriatric issues with your students?
Yes  No  N/A
 
Do you currently see geriatric patients in your practice?
Yes  No  N/A
 
Have you heard of the Long Island Geriatric Education Center?
Yes  No  N/A
 
The following information is requested to fulfill reporting requirements for the Federal Funding Agency (HRSA). Completion is voluntary.
 
Gender
Male   Female
 
Age
18-29   30-39   40-49   50-59   60-69   70-79   80-89   90-99
 
Cultural/Ethic Background
 
For the purposes of this survey, Geriatrics is defined as "health related needs of people age 65 and older."
 
For each question below, please select one:
Generally speaking, do you feel your knowledge about geriatrics is
None   Minimal   Average   Above Average   Expert Level
 
Comments
 
If I had an opportunity to increase my knowledge level about geriatrics I would be
Not Interested   Minimally Interested   Somewhat Interested   Interested   Very Interested
 
Comments
 
My impression is that the amount of training that health profession students get in geriatrics is
Not Much   A Little   Adequate   More Than Adequate   Comprehensive
 
Comments
 
Education/Training Needs

Please select the 5 geriatric education and training topics you most need.
 (Most Needed)
 (Least Needed)
 
Please add any other geriatric topics that would interest you
 
Would you be willing to attend training on your chosen topics?
Yes   No
 
What day of the week is best for you to attend training or meetings?
Sunday   Monday   Tuesday   Wednesday   Thursday   Friday   Saturday  
 
What is the best time of day for you?
Morning   Afternoon   Evening
 
Which three geriatric training materials would be most useful to you?
"How-to Manuals"
Audiotapes
Bibliographies
CD Rom Courses
Curriculum modules
Internet Resources
Other, please specify
Outlines
Slide programs
Texts
Videotapes
WebCT Courses
 
If you selected other, please specify
 
Where would you prefer to have training programs presented?
 (Most Prefer)
 (Least Prefer)
 
If you selected other, please specify