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“Safety Precautions in Older Patients: Medications, Driving Risks, & the Home Environment”
  • Date: Thursday, February 6th, 20142014-02-06
  • Time: 5:00pm - 6:30pm
  • Location: ITVITV

Registration is now open for Dr. Jicha’s upcoming AD ITV on February 6 at 6:00 pm ET.   Registration form is inserted below.

Completed registration forms can be returned to either ovargec@uky.edu or by fax to 859-323-4940.


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“Safety Precautions in Older Patients: Medications, Driving Risks, & the Home Environment”  

Presenters: Greg Jicha, MD, PhD. & Marie Smart, Family Care Specialist     
February 6, 2014 - 6:00–7:30 pm ET/5:00-6:30 pm CT


Please check which ITV site you will be attending for this presentation:

r UK Kentucky Clinic K-116               r UL HC Outpatient Center     rETSU          
rBaptist Health Madisonville             rHarlan ARH                          rMadison County Health Department

rPikeville Medical Center                  rMonroe County Medical Center rSt. Claire Center for Health Education

rPerkins Vocational Training Center  rOther: _________________________


Thank you for participating in this training program offered through the Ohio Valley Appalachia Regional Geriatric Education Center.  We sincerely appreciate your assistance in answering the questions below.

Please take a few minutes to complete this profile.  We request your information for two reasons:

v To help us secure continued federal funding.  Participant information is crucial for our reports to the Bureau of Health Professions at the U.S. Dept. of Health and Human Services/HRSA.  No personally identifiable information is included in grant reports.

v To register you for this training and include you in our database for information regarding future programs.

The information provided is kept strictly confidential.
















PLEASE PRINT        Last 4 digits of Social Security #: _________


First Name                                                                  MI                   Last Name   

Organization                                                                           Work Department

Work Address 

City                                                                                         State                            Zip code

Telephone:                                                      Counties of work

Credentials                                                     Position 

Gender      Female      Male                                                       Year of Birth   


What is your age group? 

 Less than 20 years              20 - 29 years                       30 - 39 years 

 40 - 49 years                       50 - 59 years                      60 years or over

What is your ethnicity?

 American Indian or Alaska Native                                    Asian, Specify: 

 Black or African American                                                Native Hawaiian / Other Pacific Islander

 White                                                                                  Other, Specify: 


Are you Hispanic / Latino?   Yes             No


Are you from an economically or educationally disadvantaged background?  Yes            No


In which (one) of the following areas did you grow up:rural   urban   suburban  frontier/remote


Do you serve a rural population?   Yes              No


Do you work in a Medically Underserved Community (MUC)?   Yes           No






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What is your most advanced degree? (Check one and specify degree)

 Elementary/secondary school (e.g., High school diploma, GED)           Masters Degree

 Associates Degree (e.g., AA, AS, AAS)                                       Doctorate

 Diploma (e.g., RN)                                                                         MD

 Baccalaureate Degree (e.g., BA, BS, BSN, BSW)                       DO

 Other, specify _________________________________


I plan to request continuing education for this program?   Yes         No


What is your profession? (Check only one)

Primary Care                                    Allied Health                                     Related Professions 

Allopathic Medicine (MD)                 Clinical Laboratory Sciences        Gerontology

 Family Medicine                            Dental (Hygiene/Asst/Tech)          Clinical Psychology / Counseling

 Internal Medicine                                       EMT                                              Other Counseling

 Psychiatry                                       Health Information                        Health Administration

 Other Medicine                              Home Health Aide/Med. Assist.   Nursing Home Admin.

Osteopathic Medicine (DO)               Nutrition and Food Services         Health Education

 Family Medicine                           Preventive Medicine                     Law (Attorney, Paralegal)

 Internal Medicine                                       Rehabilitation Therapies                Law Enforcement / Security

 Psychiatry                                       Technician                                      Protective Services

 Other Medicine                             Other, specify                                Pastoral Care

 Chiropractic                                                                                              Public Health

 Dentistry                                                                                                     Dental Public Health

 Pharmacy                                                                                                    Recreational Therapies

 Physician Assistant                                                                                    Social/Behavioral Sciences


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