National Center for Cultural Competence

Initiative for Decreasing Disparities in Depression CME:
Provider Self-Assessment CME Model Incorporating Cultural and Linguistic Competence in the Diagnosis and Treatment of Depression

Consent and Respondent Demographic Information

Instructions

The following questions are used to compile a demographic profile of respondents and are not intended to identify individuals. Please mark the appropriate number or fill in your responses where requested. Questions regarding age, gender, race/ethnicity will assist in capturing diversity.

Consent: Read More About this Study

Georgetown University's Institutional Review Board (IRB) requires that the research and purpose of this study be explained, including information on what kinds of questions you will be asked and your rights regarding privacy. Please read the full IRB Invitation for Research document in PDF format.

After reading the IRB document, you must agree to its terms in order to continue.

I agree to the terms of the IRB document.

You MUST check this box before continuing with the CME activity.

Demographics

Gender

Female

Male

Race and Ethnicity (These categories are based on options offered by the U.S. Census Bureau 2002.)

Race

American Indian/Alaska Native

Asian (specify)

Black (specify)

African American

Pacific Islander (specify)

White

Some Other Race (specify)

Two or More Races (specify)

Ethnicity

Hispanic

Non-Hispanic

C.	Age
	Under 30 years	31 - 40 years	41 - 50 years	51 - 60 years	Over 60 years

D.	If you are a physician, please indicate your area of practice:
		Family and Community Medicine
		Pediatrics and Adolescent Medicine
		Obstetrics-Gynecology
		Internal Medicine
		Gerentology
		Psychiatry
		Other

E.	If you are a non-physician, please indicate specialty:
		Nurse
		Nurse Practitioner
		Physician Assistant
		Psychologist
		Social Worker
		Other

F.	Information to document and deliver CME credits: NOTE: To receive CME credit, you MUST fill in the contact information below.
	Name
	Address	(street address)
		(additional address)
		(city)
		(state)
		(zip code)
	E-Mail