Information Form for<br> CORE Curriculum in Ethnogeriatrics

Information Form for
CORE Curriculum in Ethnogeriatrics

Developed by the
Collaborative on Ethnogriatric Education

We need to track the distribution of this curriculum to report to our funding agency, the Bureau of Health Professions. Please take a few minutes to answer the following questions.

Demographic Information

Your name:

Your discipline:

Your degree:

Organization:

Position:

Address:

City,state,zip:

E-mail:

Phone:

Fax:

Do you teach? Yes No
If yes, in what department?

Your ethnic background:

Curriculum Dissemination Information:

How did you hear about this curriculum?

How are you considering using this curriculum?
Evaluation
We would like to contact you at a later date to help us evaluate the curriculum. If you would be willing to complete a brief follow-up survey, please indicate the preferred method of contact:
Phone
Mail
Email
Fax
Thank you so much for completing this form.

Your name:
Your discipline:
Your degree:
Organization:
Position:
Address:
City,state,zip:
E-mail:
Phone:
Fax:

Do you teach?	Yes No
If yes, in what department?
Your ethnic background:

How did you hear about this curriculum?
How are you considering using this curriculum?

Information Form for CORE Curriculum in Ethnogeriatrics

Information Form for
CORE Curriculum in Ethnogeriatrics