1. I am taking CDR training for the following reason or reasons. Hold down the Control (Ctrl) key and left click to choose more than one.
Proficiency training required for NACC Uniform Dataset ADG-08-01 ADNI ADCS DHA Study ADCS Homocysteine Study ADCS MCI Study ADCS Prevention Instruments Study ADCS Valproate Study ADCS Study - Other/Unknown AFFiRiS006 Other Clinical Trial or Research Study (specify below) Janssen Trial (Specify in Question 2) Clinical Care Purposes Personal Interest or Professional Development Requirement of a Course or Fellowship Other (specify below)
2. If you chose an “other” or the "Janssen Trial" response in Q1, please specify the trial, study, or other purpose motivating you to seek CDR training at this time. If a pharmaceutical company is involved, please include the name of the company and an identifier for the trial (if any). Example: Baker Pharmaceuticals, Trial AC3345 MCI. You may also include other comments to explain your reasons for seeking training. This website is partially funded by the NIA and this information is helpful for annual grant reporting.
3. Please rate your current knowledge of the CDR: Select None/Very Limited Fair Good Very Good
4. First Name: Middle Initial Last Name:
5. Degree(s):
6. Profession and/or Title:
7. Institution, Corporation or Organization:
ADCS/ADNI Site Number (if applicable):
8. City:
9. State (if applicable): Select One Alaska(AK) Alabama(AL) Arkansas(AR) Arizona(AZ) California(CA) Colorado(CO) Connecticut(CT) District of Columbia(DC) Delaware(DE) Florida(FL) Georgia(GA) Hawaii(HI) Iowa(IA) Idaho(ID) Illinois(IL) Indiana(IN) Kansas(KS) Kentucky(KY) Louisiana(LA) Massachusetts(MA) Maryland(MD) Maine(ME) Michigan(MI) Minnesota(MN) Missouri(MO) Mississippi(MS) Montana(MT) North Carolina(NC) North Dakota(ND) Nebraska(NE) New Hampshire(NH) New Jersey(NJ) New Mexico(NM) Nevada(NV) New York(NY) Ohio(OH) Oklahoma(OK) Oregon(OR) Pennsylvania(PA) Rhode Island(RI) South Carolina(SC) South Dakota(SD) Tennessee(TN) Texas(TX) Utah(UT) Virginia(VA) Vermont(VT) Washington(WA) Wisconsin(WI) West Virginia(WV) Wyoming(WY) ----- American Samoa(AS) Federated States of Micronesia(FM) Guam(GU) Marshall Islands(MH) Northern Mariana Islands(MP) Palau(PW) Puerto Rico(PR) Virgin Islands(VI) ----- Armed Forces Africa(AE) Armed Forces Americas(AA) Armed Forces Canada(AE) Armed Forces Europe(AE) Armed Forces Middle East(AE) Armed Forces Pacific(AP)
10. Country: Select One Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (DRC) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Islands Finland France France, Metropolitan French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Authority Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino Sao Tomé and Príncipe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands Virgin Islands, British Wallis and Futuna Yemen Yugoslavia Zambia Zimbabwe
Zip/Postal Code:
11. E-mail Address:
12. Telephone Number (incl. area code):
13. Do you currently provide clinical care or a health-related service to older adults? Select Yes No
14. Do you provide clinical care to persons residing in rural or semi-rural areas?
Select One Yes, many of my patients/clients are from rural locations Yes, a few of my patients/clients are from rural locations. No, I see patients/clients but not from rural locations. No, I don't provide clinical care to patients/clients.