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* 1. Name:

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* 2. Title:

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* 3. Practice/Organization

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* 4. Email:

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* 5. Please indicate any NNECOS educational activities in which you have participated in the past:

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* 6. Preferred methods to receive education

  Very interested Moderately interested Somewhat interested Not interested
Person to person
Meetings / conferences
Formal courses
Videos
Teleconferences
Internet
Journal club

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* 7. Factors that impact the decision to participate in education: (check all that apply)

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* 8. Please check up to 10 educational priorities/areas of interest

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* 9. What schedule of CE activities are you more likely to attend? (Check all that apply)

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* 10. How often do you access NNECOS website?

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* 11. Are you aware of the NNECOS speakers list for educational activities?

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* 12. Would you like to be contacted by a member of the educational committee for help in setting up a meeting at your institution

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* 13. Would you be interested in participating in multi-institutional trials & learning more about potential collaborative research opportunities?

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* 14. Please share any additional comments regarding how NNECOS can help meet your educational needs:

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