Thank you for your interest in SWCAHEC’s Educational Video Series. Please complete this short form and you will be redirected to a video link. THANK YOU!

Introduction to Understanding Alzheimer's Disease - Video Registration Form

Name
Is your current mailing address in Colorado?(Required)
Address
Employer Medically Underserved Community
Employer Rural Site
Employer Primary Care Site
CO AHEC receives some funding from the federal government. Because of this, we are required to collect demographic information and submit a report twice a year. No individual-level data are shared and your personal information is kept confidential. The Office of Management and Budget (OMB) has issued a 3-year approval for the annual collection of performance measures across all grants and cooperative agreements funded through the Health Resources and Services Administration's Bureau of Health Workforces (BHW) (OMB # 0915-0061; Expiration Date: 06/30/2019). For more information please see: https://www.gpo.gov/fdsys/pkg/FR-2017-04-25/pdf/2017-08295.pdf
Age group(Required)
Race (choose one)(Required)
Ethnicity(Required)
Gender(Required)
Do you reside in a Rural Area?(Required)
Are you from a Frontier Area (sparsely populated area isolated from populated centers and services)?
Veteran Status(Required)
Are you from a Disadvantaged Background?(Required)
Do you reside in a Medically Underserved Area?(Required)