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An Applied Doctoral Research Project
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Participant Demographics
and Practice Survey
First name
*
Last name
*
Telephone number
*
Email address
*
Department or Unit
*
What is your current position?
*
1. What is your age? (Please select one)
18 - 30 [1]
31 - 40 [2]
41 - 50 [3]
51 -60 [4]
61 -70 [5]
71 - 80 [6]
80 and Over [7]
Prefer not to respond [8]
2. Gender Identity (Please select your gender)
3. Race (Please choose your race)
Highest education level (Please select your highest level of education)
Licensure Provider (Please check all that apply)
Physician [1]
Nurse practitioner [2]
Physician Assistant [3]
Nurse [4]
Social worker [5]
Certified public accountant [6]
Certified management accountant [7]
Certified financial accountant [8]
PHR / SHRM / HRCI [9]
Other [10]
6. Main area of practice (Please select one)
*
Emergency medicine [1]
Family practice [2]
Health Education [3]
Hematology/Oncology [4]
Hematology/Oncology-SCD specialty [5]
Internal medicine [6]
Nephrology [7]
Neurology [8]
Pain management[9]
Primary care [10]
Prefer not to provide [11]
Other [12]
Years in discipline/practice
8. Are you a clinical provider?
*
No
Yes
Please complete the
Sickle Cell Disease Questionnaire
If your answer is "
Yes
"
Next
Sickle Cell Disease Questionnaire
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