0 1-5 More than 5
| INSTRUCTIONS: PLEASE PRINT OUT, COMPLETE AND RETURN AS INDICATED BELOW. |
1. How many NYSSA PGA Meetings have you attended?
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0 |
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1-5 |
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More than 5 |
2. Are you an NYSSA Member?
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Yes |
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No |
3. Are you a/an?:
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M.D. (or equivalent) |
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D.O. |
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CRNA |
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Resident |
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Other _________________________________ |
4. What is your Anesthetic Practice?
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Private Practice Fee-for-Service |
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Private Practice Group |
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Hospital Salaried |
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Academic |
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Other _________________________________ |
5. How many years have you been in practice?
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Less than 5 |
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5-10 |
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More than 10 |
6. In what type of community do you practice?
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Urban |
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Suburban |
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Rural |
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Other _________________________________ |
7. How many CME Activities have you attended in the past 12 months?
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0 |
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1-3 |
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3-5 |
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More than 5 |
8. What sessions/learning styles do you find most helpful to you in your practice? (Mark in the box in order of preference, i.e., 1, 2, 3, etc.)
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Scientific Panels (large audience sessions) |
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Focus Sessions (singular topic discussed in depth) |
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Workshops - Hands-On Interactive |
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Miniworkshops |
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Problem-Based Learning Discussions |
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Case Discussion Luncheons With the Experts (small group lectures) |
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Poster Presentations |
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Scientific Exhibits |
9. Are there any educational interests that you would like to see addressed at future CME Meetings?
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_________________________________________________________________ |
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_________________________________________________________________ |
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_________________________________________________________________ |
Comments:
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_________________________________________________________________ |
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_________________________________________________________________ |
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_________________________________________________________________ |
10. Are there any questions on any practice-related problems you may have that you would like us to direct to a specific faculty member regarding topics that will be presented at the PGA this coming December?
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_________________________________________________________________ |
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_________________________________________________________________ |
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_________________________________________________________________ |
| Please print out and return by fax to: | 1-212-867-7153 |
| Or, by mail to: | The NYSSA 85 Fifth Avenue 8th Floor New York, NY 10003 (U.S.A.) |
| Or, by e-mail to: | NYSSA Headquarters |
| Please give us your: | ____________________________________ NAME |
| ____________________________________ ADDRESS |
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| ____________________________________ CITY |
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| ____________________________________ STATE/POSTAL CODE |
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| ____________________________________ COUNTRY |
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| ____________________________________ |