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Select a course date*
Monday May 17 & Tuesday May 18 – 8:00am-4:00pm – 8:00am-4:00pm

Salutation
Dr.
Ms.
Mr.

First Name* Last Name*

Organization*

Position / Job Title*

Discipline*

Email*

Make sure you use a valid email address

Daytime Phone number and extension*

Practice Location*
Community
Inpatient
Outpatient
Emergency Department
Long-term Care Facility

Please select if you work in any of the following areas of Specialized Geriatric Services:
Geriatric Assessment Outreach Team
Geriatric Day Hospital
Geriatric Emergency Medicine
Geriatric Inpatient
Geriatric Consultation Team
Geriatric Rehabilitation Unit
Geriatric Psychiatry

Please list 3 things you are hoping to take away from this course*

Please rate your knowledge in the following six areas (scale: 1: limited knowledge to 7: expert knowledge)*
Frailty rate your knowledge 1 2 3 4 5 6 7
Dementia rate your knowledge 1 2 3 4 5 6 7
Depression rate your knowledge 1 2 3 4 5 6 7
Delirium rate your knowledge 1 2 3 4 5 6 7
Falls rate your knowledge 1 2 3 4 5 6 7
Mobility rate your knowledge 1 2 3 4 5 6 7
Capacity rate your knowledge 1 2 3 4 5 6 7
Risk rate your knowledge 1 2 3 4 5 6 7

Other Comments