NeuroRehab Needs Assessment Survey

To enable us to maintain the highest scientific and statistical standards when analyzing the survey results, please complete the registration form before taking the survey.

Online Registration Form

An asterick (*) indicates a required field.
*First name:  Middle initial: 
*Last name:  Age: 
*Degree(s)/ 
certification(s): 
MD
PhD
 DO
NP
 PA
RN
 Other
    
*Years in practice: 
Resident
Fellow
 <5
5–9
 10–14
15–19
 ≥20
*Specialty: 
Neurology
Physical medicine
and rehabilitation
 Internal medicine
Other (Please specify)
    
 
*Practice type: 
Hospital-based
University-based
Private practice
 Clinic
Home care
Long-term care
Title:  Affiliation: 
 *Address 1:  Address 2: 
*City:  *State: 
 *ZIP:  Daytime phone: 
Fax:  *E-mail: 
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Please do not send me information via e-mail.

We value the confidentiality of the information you choose to share with us and are committed to its protection. All personal information you provide is stored in a secure location and will never be sold or distributed to any third party.


The NeuroRehab Preceptor Program is jointly sponsored by the Annenberg Center for Health Sciences at Eisenhower and CogniMed Inc.

This program is supported by an independent educational grant provided by Allergan, Inc.

© 2010 CogniMed Inc. All rights reserved.