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CardioNerds September 2021
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
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3.
Email Address
(Required.)
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4.
Age in years
(Required.)
<20
20-29
30-39
40-49
50-59
60-69
>70
5.
Gender (optional)
Woman
Man
Transgender
Non-binary/non-conforming
6.
Race – Please check all which apply (optional)
White
Hispanic, Latino, or Spanish origin
Black or African American
Asian
American Indian or Alaska Native
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Other
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7.
In what country do you work?
(Required.)
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic People's Republic of Korea
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People’s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Federated States of)
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
State of Palestine
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Tajikistan
Thailand
The former Yugoslav Republic of Macedonia
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United Republic of Tanzania
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Vietnam
Yemen
Zambia
Zimbabwe
8.
If you answered the United States for Question 7, please indicate in what state or U.S. territory you currently work.
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
9.
Level of Training
Student
Resident
Fellow
Post-training / Practicing
N/A
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10.
Current/future occupation
(Required.)
Physician (MD, DO, MBBS, in-training)
APP (PA, NP, CRNA, in-training, etc.)
First Responders (EMS, etc.)
Nurse
Nonclinical scientist/researcher
Pharmacist (PharmD, in-training)
Industry Affiliate
N/A
*
11.
Current/future subspecialty(ies) – Please check all which apply
(Required.)
Clinical Cardiology
Interventional Cardiology
Electrophysiology
Advanced Heart Failure & Transplant
Cardiovascular Imaging
Adult Congenital Heart Disease
Cardio-oncology
Cardio-obstetrics
Women’s CV Health
Cardiovascular Prevention
Critical Care Cardiology
Sports Cardiology
Vascular Medicine
Other Cardiology
Non-Cardiology
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12.
How many ACC CardioNerds Narratives recordings have you watched prior to this one? (1-18)
(Required.)
This is my first
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
For each of the following questions, please select the single best answer.
Diversity
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13.
A more diverse cardiovascular medicine workforce would lead to better patient care.
(Required.)
Strongly disagree
Disagree
Indifferent
Agree
Strongly agree
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14.
I feel that diversity of the cardiovascular medicine workforce is adequate.
(Required.)
Strongly disagree
Disagree
Indifferent
Agree
Strongly agree
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15.
I feel that my program/place of work values diversity among the workforce.
(Required.)
Strongly disagree
Disagree
Indifferent
Agree
Strongly agree
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16.
I feel comfortable openly discussing or asking others about factors that make them different from myself like their race, religion, ethnicity, gender, sexual orientation, immigration status, etc.
(Required.)
Strongly disagree
Disagree
Indifferent
Agree
Strongly agree
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17.
I feel comfortable openly discussing factors that make me different from others like race, religion, ethnicity, gender, sexual orientation, immigration status, etc.
(Required.)
Strongly Disagree
Disagree
Indifferent
Agree
Strongly Agree
Cardiology
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18.
I feel that cardiology as a field is accommodating of good work-life integration.
(Required.)
Strongly disagree
Disagree
Indifferent
Agree
Strongly agree
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19.
I feel that I have adequate opportunity for mentorship and professional development in cardiology.
(Required.)
Strongly disagree
Disagree
Indifferent
Agree
Strongly agree
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20.
I would be likely to choose cardiology as a career going forward (if you are pre-cardiology fellowship) or choose cardiology again if given another opportunity (if you are already in training or practicing).
(Required.)
Yes
No
Maybe
21.
Please add any additional comments.