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Last Name: Last 4 digits of SSN: First Name: Email: Zip Code: Birth Year: Gender: Female Male Race: Check ALL that apply African American/Black Asian Caucasian/White American Indian/Alaskan Native Native Hawaiian/Pacific Islander Other No Response Are you Hispanic / Latino? Yes No Background & Training: (check all that apply) Allopathic Medicine (MD) Osteopathic Medicine (DO) Chiropractic Dentistry Nursingc Pharmacy Physician Assistant Podiatry Rehabilitation Therapies Other Allied Health Profession Clinical/Counseling Psychology Other Counseling Health or Nursing Home Administration Law/Law Enforcement Protective Services Pastoral Care Social/Behavioral Sciences Social Work Other Student / Faculty / Practitioner: (check all that apply) Student Faculty Practitioner Does your place of work or school emphasize service to any of the following groups? (check all that apply) Older Adults Rural Population Inner City Population Minority Groups Low Income Area

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