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2020 ECHO Demographics

Form LR-2; DV-1 (Hispanic Q 3), DV-2 (Disadvantaged Q 8); DV-3 (Rural background Q 1f-1g), INDGEN Subforms (all - Q8), IND-GEN Block 3 (Q5), Block 4 (Q2), Block 6a (Q1c), Block 6 (Q3), Block 7 (Q4), Block 8 (Q1f-1g), Block 9 (Q8), Block 10 (Q6-7), Block 11 (Q15-16), Block 12 (Q17), Block 15 (Q12-13), Block 15 (Q9), Block 16 (Q18-25), Exp-2 Block 3(Q18-25)

Form CE-1: Block 9, 9a-9c (Location of workplace) //
This training is supported in part through funding from HRSA, DHHS, grant U1QHP33111, Geriatrics Workforce Enhancement Program.  We are required to collect data and report that information in a group format.  Please complete the below form to assist us in planning future trainings and receiving continued funding.
 
1. Please note all fields are required. *This question is required.
This question requires a valid email address.
This question requires a valid number format.
If outside the U.S., please put NA. You will be asked to report the country in a separate question.
If outside the U.S., please put NA. You will be asked to report the country in a separate question.
2. What is your gender?
MaleFemale
3. Are you Hispanic / Latinx?
YesNo
4. What is your race / ethnicity?Please check all that apply.
  • * This question is required.
5. Are you currently employed:
Full TimePart TimeOn LeaveRetired
6. Have you ever served in the armed forces / reserves?
YesNo
What is your veteran status?
Active Duty MilitaryReservistVeteran - Prior ServiceVeteran - Retired
7. Please answer each question below.
Space Cell YesNo
Are you a first generation college graduate?
Did your high school have a low graduation rate?
Did your high school have a low percentage of graduates that attended college?
Did you high school have a large percentage of individuals that qualified for free / reduced cost lunches?
Did your family receive public assistance (e.g., food stamps, housing assistance)?
For the majority of your childhood, did you live in a rural community and/or area?
8. What is your primary role?
Health Professional / ProviderUniversity / College FacultyFellowResidentStudentOther
Are you in a graduate / advanced degree program?
YesNo
This question requires a valid number format.
This question requires a valid number format.
9. Do you supervise or provide instruction to health professions students?
YesNo