The Charles F. and Joanne Knight Alzheimer's Disease Research Center

Community Interaction Reporting Form

Would you like a paper version of the form below? Click HERE for a PDF version.

Purpose: The Knight ADRC Education Core is grant-mandated to track community interactions and education events. Please complete this form with as much information as you can provide. If you have questions, please contact Jennifer Phillips, MPA at (314) 286-2881. Please submit only one event per form.

* Denotes mandatory fields that must have a response before the form will submit properly. However, you should answer all questions to the best of your ability.

* Name(s) of Presenter(s):

* Date of Event: <-- use our calendar to pick the date

* Title of Presentation:

* Type of Interaction: If Other:

* Host Organization

* Type of Organization

* Location/Venue

* City

* State

* Total Number of Attendees (estimates acceptable):

Ethnicity of Attendees (please estimate in whole percentages, leave blank if 0):

% Caucasian
% African American
% Asian
% Hispanic
% Other

Audience Composite (please estimate in whole percentages, leave blank if 0):

% Physicians (including medical students, residents and fellows)
% Academic Scientists
% Nursing
% Psychology / Social Work
% Professionals - Other / Undefined
% Lay

Ages of Attendees (please estimate whole percentages, leave blank if 0):

%< 18
% 18 - 64
% 65 and older

Number of people signed up to be called about research:
Number of people inquiring about additional educational events:

Comments:

(Maximum characters: 900)

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