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 email@example.com or by fax to 859-323-4940.
OVAR/GEC REGISTRATION FORM
“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
City State Zip code
Telephone: Counties of work
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
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