Virginia Geriatric Education Center (VGEC)
Demographic Survey
Instructions: In order to report on this project for the Bureau of Health Professions, Health Resources and Services Administration, this
questionnaire should be completed by everyone who participates in VGEC training. You must be 18 years of age or older to participate in
training. Your answers are extremely valuable and important for continued grant funding (Grant No. U1QHP28744). This and any
other forms you complete related to this project are strictly confidential. We ask that you provide a personal code so that your responses to
training evaluation questions will not be linked with your name in any data base. Your contact information will be used only for tracking
purposes and we will not share it with anyone for any reason. All results reported back to the funder will be grouped, so that no single person
or organization may be distinguished. Your participation in this survey is voluntary. If you choose to participate, you may stop at any time
without any penalty and you may also choose not to answer particular questions that are asked in this survey. We thank you for your
participation.
Personal Code:
Circle first letter of mother’s first name:
Circle first letter of mother’s maiden name:
Circle first letter in the city of your birth:
Circle first letter in state of your birth:
ABCDEFGHIJKLMNOPQRSTUVWXYZ
ABCDEFGHIJKLMNOPQRSTUVWXYZ
ABCDEFGHIJKLMNOPQRSTUVWXYZ
ABCDEFGHIJKLMNOPQRSTUVWXYZ
Please provide your year of birth (YYYY):
_______________
Date:
Name:
Email address:
The following demographic information is used only to encourage funding support for underserved
communities:
1. Age Group:
2. Gender:
19 or younger
40-49 years old
Male
(Check only ONE)
30-39 years old
60-69 years old
70 years or older
Female
3. Are you Hispanic or Latino?
4. Race/Ethnicity
20-29 years old
50-59 years old
Yes
No
American Indian or Alaska Native
African American or Black
Caucasian or White
Asian: (Specify)
Native Hawaiian / Other Pacific Islander
Other: (Specify)
5. Do you consider yourself ever to have been from an economically disadvantaged background?
Yes
No
Yes
No
(i.e. From a family with an annual income below federal low income thresholds?)
6. Do you consider yourself ever to have been from an educationally disadvantaged background?
(i.e. From an environment which inhibited obtaining knowledge, skill, and abilities required to enroll in and graduate
from an allied health or health professions school?)
7. In which kind of community did you grow up? (Select Only One)
Urban/Inner City
Suburban
Rural
Frontier*
*A remote area in which weather and distance can prevent severely injured or ill patients from getting immediate transport to an acute care hospital.
8. Location of your primary work/practice:
City
OR
County
AND
State
9. What is your current, or most recent, job title?
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Virginia Geriatric Education Center (VGEC)
Demographic Survey
10.
Please check your primary discipline. Please check only ONE.
Fellows, residents, providers, faculty, and practicing professionals
Medicine
Chiropractor
Dermatology
Emergency Medicine
Family Medicine
General Preventive Medicine
Geriatric Psychiatry
Geriatrics
Gynecology
Integrative Medicine
Internal Medicine
Internal Medicine/Family Medicine
Medical Genetics
Medicine—Other
Neurological Surgery
Neurology
NP—Acute care adult gerontology
NP—Acute Care Pediatric
NP—Adult
NP—Adult gerontology
NP—Adult Psychiatric/Mental health
NP—Emergency care
NP—Family
NP—Family Psychiatric/Mental Health
NP—Geropsychiatric
NP—Women’s health
Nuclear Medicine
Occupational Medicine
Ophthalmology
Orthopedic Surgery
Otolaryngology
Pathology—Anatomical and Clinical
Pharmacy
Physical Medicine and Rehabilitation
Physician Assistant
Podiatry
Preventive Medicine/Family Medicine
Preventive Medicine/Internal Medicine
Preventive Medicine/Occupational Med
Preventive Medicine/Public Health
Psychiatry
Radiation Oncology
Radiology—Diagnostic
Surgery—General
Urology
Public Health
Biostatistics
Disease Prevention & Health Promotion
Environmental Health
Epidemiology
Health Policy & Management
Infectious Disease Control
Injury Control & Prevention
Social & Behavioral Sciences
Allied Health
Nutritionist
Occupational Therapy
Optometry
Physical Therapy
Respiratory Therapy
Speech Therapy
Behavioral Health
Clinical Psychology
Clinical Social Work
Counseling Psychology
Marriage and Family Therapy
Other Psychology
Other Social Work
Pastoral/Spiritual Care
Substance Abuse/Addictions Counseling
Dentistry
Dental Assistant
Dental Hygiene
General Dentistry
Other
Public Health Dentistry
Nursing
Alternative/ Complementary Nursing
CNL—Generalist
CNS—Adult gerontology
CNS—Family
CNS—Geropsychiatric
CNS—Psychiatric/Mental health
CNS—Women’s health
Community Health Nursing
Home Health Aide
LPN/Vocational Nurse (LPN/LVN)
Medical Assistant
Nurse administrator
Nurse anesthetist
Nurse educator
Nurse informaticist
Other (e.g., CNA, PCA)
Public Health Nurse
Registered Nurse
Researcher/Scientist
Other
Allied Health
Lay and Family Caregiver
Office/Support Staff
Other—Community Health Worker
Other—Direct Service Worker
Other—Facility Administrator
Other—First Responder/EMT
Other—Health Education Specialist
Other—Health Informatics/Health IT
Students
Allied Health
Alternative/ Complementary
Nursing
Behavioral Health
Certified Nursing Assistant
Chiropractic
Clinical Laboratory Services
Clinical Nurse Leader (CNL)
CNS - Adult gerontology
CNS - Family
CNS - Geropsychiatric
CNS - Psychiatric/Mental health
CNS - Women’s health
Community Health Nursing
Dental Assistant
Dental Hygiene
Dental School
Home Health Aide
LPN/Vocational Nurse
Medical Assistant
Medical School
NP—Adult
NP—Adult gerontology
NP—Emergency care
NP—Family
NP—Family Mental Health
NP—Geropsychiatric
NP—Mental health
NP—Other
NP—Women’s health
Nurse Administrator
Nurse Anesthetist
Nurse Educator
Nurse Researchers/Scientists
Nursing Doctorate
Nursing Informatics
Nursing Masters
Occupational Therapy
Optometry
Pharmacy
Physical Therapy
Physician Assistant
Podiatry
Psychology
Public Health
Public Health Nurse
Radiological Assistant
Registered Nurse
Rehabilitation Therapy
Social Work
Speech Language Pathology
Profession Not Listed
Please Specify:
Student Discipline Not Listed
Please Specify:
________________________________
_________________________
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Virginia Geriatric Education Center (VGEC)
Demographic Survey
11. How many years have you been practicing in your discipline?
12. Highest degree you hold:
Elementary / Secondary School (general, technical, vocational)
Associate’s Degree
Certificate or Diploma
Baccalaureate Degree
Other, specify
Master’s Degree
Doctorate
MD
DO
13. Credentials you’ve earned: (ex: CNA, BA, RN, MD, etc)
14. Will you apply this VGEC training toward employment requirements, continuing education credit, national certification,
or credentialing?
Yes
No
15. I am a family/informal caregiver.
Yes
No
16. I am a fellow.
Yes
No
17. I am a resident.
Yes
No
18. I am an undergraduate student.
Yes
No
19. I am a graduate student.
Yes
No
20. Do you have a faculty appointment at an institution of higher education?
Academic Faculty – Part-time
Academic Faculty – Full-time
Clinical Faculty – Part-time
Clinical Faculty – Full-time
21. I work in a Medically Underserved Community (MUC)
Yes
No
I don’t know.
MUC is a geographic location or population of individuals that is eligible for designation by a state or the federal government as a
health professions shortage area; medically underserved area and/or medically underserved population.
22. I work in a Health Professionals Shortage Area (HPSA)
Yes
No
I don’t know.
Areas having shortages of primary medical care, dental or mental health providers and may be geographic (a county or service
area), demographic (low income population) or institutional (comprehensive health center, federally qualified health center or other
public facility).
23. I work in a Rural setting
Yes
No
I don’t know.
24. I work in Primary Care
Yes
No
I don’t know.
Primary care is the provision of integrated, accessible health services by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and
community.
25. Your geriatric education needs. Identify the three (3) aging and health topics below most important to the work that you do.
PLEASE ONLY CHECK THREE (3) TOPICS.
Healthy Aging
Diabetes
Pain Management
Geriatric Assessment
Mental Health and Aging
Falls Prevention
Elder-caregiving
Arthritis
Cultural Sensitivity
Physiology of Aging
Medications/Polypharmacy
Physical Rehabilitation
Substance Abuse
Ethics
Health Care Literacy
Community-based care
Nutrition and Diet
Medicare/Medicaid
Osteoporosis
Palliative Care
Depression
Dementia
Elder Abuse
Other:
End of survey. Thank you very much for your time and consideration!