Needs Assessment :: Arkansas Geriatric Education Center (AGEC)

Help us plan future geriatric programs by indicating the most useful Medical Health Issues and Topics in Aging as they relate to your practice.

Medical Health Issues (Select Five)
Alzheimer’s			Malnutrition
Anxiety			Menopause
Aphasia			Mood Disorders
Arthritis			Neurological Disorder
Breast Cancer			Osteoporosis
Colon Cancer			Ovarian Cancer
Depression			Parkinson
Diabetes			Pressure Ulcers
GI Disorders			Prostate Cancer
Hearing Loss			Pulmonary Disease
Heart Disease			Skin Cancer
Hypertension			Sleep Disorders
Incontinence			Stroke
Infectious Diseases			Substance Abuse
Lung Cancer			Vision Loss

Topics in Aging (Select Five)
Acute Care			Mental Health
Disease Prevention			Nutrition and Aging
Ethical Issues			Oral/Dental Care
Exercise			Palliative Care
Falls/Accident Prevention			Psychosocial Problems
Health Promotion			Drugs and Elders
Home Healthcare			Rehabilitation
Hospice Services			Sexuality
Legal Issues			Subacute Care
Long-Term Care Options			Veterans' Care
Memory Loss

The AGEC is participating in a special project regarding Veterans’ healthcare needs. We appreciate your response to the following questions.
Would you welcome clinical education on Veterans’ mental health?
Yes No
Would you welcome clinical education on Veterans’ physical health?
Yes No
About what percentage of your patients/clients/residents are Veterans?
%
About what percentage of your patients/clients/residents are Veterans 65+?
%
If you wish to receive provider education regarding Veterans’ health, please provide an e-mail address or phone number where we may contact you:
Phone:	Email:

Please rate the usefulness of the following media.	Never Used	Useful Very ‹—› Not
Conferences/Seminars
Newsletters
Self-study educational materials
Telephone conferences
Video teleconferences (VTCs)
Web based continuing education courses
Webinars
Web sites

Please answer the following questions.

Do you use a computer for educational training purposes?

Yes No

Can you receive video teleconferences in your area?

Yes No

Would you travel up to 40 miles to attend conferences/seminars?

Yes No

How would you prefer to view a pre-recorded program?

CD DVD VHS Web

How could the AGEC best provide programs to you?

CD DVD Live VHS Workbook Other

Do you visit the AGEC website (http://www.agec.org)?

Frequently Occasionally Never

What additional information or links would you like to see in our website?

Do you read the AGEC’s Vision newsletter?

Frequently Occasionally Never

What topics would you like to read about in our newsletter?

How would you prefer to hear about educational programs?

Brochure E-mail Newsletter Postcard Website

Demographic Information
Age:		Race: (Check all that apply)
20 - 29		American Indian
30 - 39		Asian/Asian American
40 - 49		Black/African American
50 - 59		Hawaiian/Pacific Islander
60+		Hispanic/Latino
		White
		Other (specify):

Gender:		WorkZip:
Male
Female

WorkPlace:
Community Clinic		Private Practice
Educational Site		Rural Clinic
Home Healthcare		VA Facility
Hospital		Other (specify):
Nursing Home		Other (specify):

HealthProfession:
Administration		Occupational Therapy
Adv Practice Nursing		Osteopathic Medicine
Allopathic Medicine		Pharmacy
Audiology/Speech Path		Physical Therapy
Dental		Physician Assistant
Emergency Med. Tech.		Psychology
Gerontology		Respiratory Therapy
Kinesiology		Social Work
Medical Tech/Rad Tech		Student
Nutrition/Dietetics		Other:
Nursing/Nursing Staff		Other:

Suggestions or ideas. Please assist us in making our geriatric educational offerings more useful to your practice by sharing your suggestions and ideas for future clinical content.

Thank you!

The Arkansas Geriatric Education Center (AGEC) at the University of Arkansas for Medical Sciences is trying to assess the educational needs in geriatrics that will enhance your practice. We want your input because your needs and those of health professionals such as you are important to us. By completing this questionnaire, you will be of great help to us.

We have appreciated the information provided by respondents in our previous needs assessment and have used it to plan our programs. Please help us to meet your educational needs and to improve the quality of healthcare for older Arkansans.

Sincerely,
Ronni Chernoff, PhD
Ronni Chernoff, PhD, RD
Director

Demographic Information

Thank you!