Exit this survey SWTRC Learning Library Demographics At the completion of this survey you will receive a username and password to access the videos Question Title * 1. Please provide the following Name: * Organization: City/Town: State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Email Address: * Phone Number: Question Title * 2. What is your role in telehealth/telemedicine (check all that apply)? Clinical (MD/DO) Clinical (DDS/DMD) Clinical (RN/LPN/CNM) Clinical (RT/PT/OT) Clinical (PA) Clinical (PhD) Program Director CEO CFO CIO Business Manager Administrator Marketing IT Network Engineer Training Site Coordinator Technical Coordinator Education Quality/Legal & Regulatory Research Other (please specify) Question Title * 3. What type of healthcare organization do you work in (check all that apply) Academic Institution / School Association / Organization Area Health Association Clinic Free Clinic Federally Qualified Health Center (FQHC) Rural Health Clinic (RHC) Clinical - Private Practice Clinical - General Funders (Foundations / Health Plans) Foundations Hospital / Health System Critical Access Hospital (CAH) Small Hospital Improvement Program (SHIP) Non-Profit Hospital / Health System Government Agency Corrections Medicaid / Medicare Public Health Social Service State Office of Rural Health (SORH) Legislator / Policy Maker Legal Telehealth Resource Center Tribal / IHS Vendor Vendor - Business Solutions Vendor - Clinical Service Provider Vendor - Technology Vendor - Telecommunications Question Title * 4. Are you a HRSA Grant Funded Entity? Yes No Not Sure Question Title * 5. Where are you located? Arizona Colorado Nevada New Mexico Utah Other Question Title * 6. Does your organization currently utilize telemedicine? Yes No Not Sure Question Title * 7. If yes, in what capacity (mark all that apply). Provides patient referrals Provide clinical consultations Administration Attending continuing education Technical support Other (please specify) Question Title * 8. How long has your organization been involved with telehealth/telemedicine? 0 years 1-3 years 4-6 years 7-10 years 11-14 years 15-18 years 19-22 years >23 years Not sure Question Title * 9. How long have you been involved in telehealth/telemedicine? 0 years 1-3 years 4-6 years 7-10 years 11-14 years 15-18 years 19-22 years >23 years Question Title * 10. How many telehealth/telemedicine training events have you attended? Never 1 2 3 4 5 or more Question Title * 11. How did you receive your telehealth/telemedicine training (check all that apply)? In-person course or session Telehealth Resource Center On-line course or tutorial From another On-line course or tutorial Course at professional meeting Text book review CD/DVD course Other (please specify) Next
