HardCopySurveyPedDip

HardCopySurveyPedDip - 1. Please enter your survey user ID...

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Unformatted text preview: 1. Please enter your survey user ID below. **This number can be found at the bottom of your initial letter.** 1. User ID Unless otherwise specified, please choose the one best answer that applies to you and your practice. 2. Gender: 3. Ethnicity: 4. Race: 5. Marital Status: 2. Demographic Data Do not wish to answer n m l k j Female n m l k j Male n m l k j Do not wish to answer n m l k j Hispanic or Latino n m l k j Not Hispanic or Latino n m l k j Do not wish to answer n m l k j American Indian or Alaskan Native n m l k j Asian n m l k j Native Hawaiian or Other Pacific Islander n m l k j Black or African American n m l k j White n m l k j Do not wish to answer n m l k j Single/Never Married n m l k j Married n m l k j Separated or Divorced n m l k j Widowed n m l k j Living with a Partner n m l k j Unless otherwise specified, please choose the one best answer that applies to you and your practice. 6. Years in practice: 7. Hours per week you practice chiropractic: 8. Gross annual income from practicing chiropractic: 9. Number of patients per week you personally provide care to: 10. Size of the community in which your practice is located: 3. Demographic Data Do not wish to answer n m l k j 10 or fewer n m l k j 11-19 n m l k j 20-29 n m l k j 30-39 n m l k j 40-49 n m l k j 50-59 n m l k j 60 or more n m l k j Do not wish to answer n m l k j $81,000 or less n m l k j $81,000 - $200,000 n m l k j $200,000 or more n m l k j Do not wish to answer n m l k j Fewer than 50 n m l k j 50-99 n m l k j 100-149 n m l k j 150-199 n m l k j 200-249 n m l k j 250-300 n m l k j More than 300 n m l k j Do not wish to answer n m l k j City n m l k j Suburb n m l k j Small town n m l k j Small town/Rural n m l k j Rural n m l k j Unless otherwise specified, please the one best answer that applies to you and your practice. 11. Highest level of non-chiropractic education attained: 12. Pediatric Diplomate program did you receive your accreditation from: 13. Would you refer a colleague to this program? 14. Year you received your Pediatric Diplomate accreditation: 15. Do you have any other post-graduate diplomate status (or equivalent) through an ACA or ICA specialty board, council, academy, college, or association: 4. Demographic Data Do not wish to answer n m l k j High School Diploma n m l k j Associate Degree n m l k j Bachelors Degree n m l k j Masters Degree n m l k j Doctoral Degree n m l k j Other (please specify) n m l k j Do not wish to answer n m l k j ICCP n m l k j ICA n m l k j ICPA n m l k j Do not wish to answer n m l k j No n m l k j Yes n m l k j Additional comments about the program: Do not wish to answer n m l k j None/Does not apply n m l k j Working toward diplomate status (or equivalent)[please specify] n m l k j Earned diplomate status (or equivalent)through an ACA or ICA specialty board, council, academy, college, or association....
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This note was uploaded on 01/03/2012 for the course C 504 taught by Professor Long during the Fall '11 term at Palmer Chiropractic.

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HardCopySurveyPedDip - 1. Please enter your survey user ID...

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