DEMOGRAPHICS
1.
Specialty
(check all that apply)
Physical Therapist
Occupational Therapist
Massage Therapist
Registered Nurse
Nurse Practitioner
PhD - specify area of study:
Physician - please
specify:
Physical Medicine
Surgical - specify specialty:
Oncology - specify specialty:
Lymphology
Vascular
Other:
Other:
2.
Current Practice Location
U.S.:
(please select a state)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Non-U.S.:
(please select a country)
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint LUCIA
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
3.
Type of Practice
(check all that apply)
University Practice
VA
Hospital /Hospital-based
Research
Managed Care Organization
Free Standing Treatment Center
Other:
4.
Primary Work Responsibilities (check all that apply)
Clinical Patient Care
Academic Educator
Administrative
Research
Other:
RESEARCH BACKGROUND
5.
Have you had any formal research training?
No
Yes - please specify:
PhD
Master’s Degree
Course
Other:
6.
Have you previously attended the Grant Writing Seminar at the NLN conferences?
No
Yes - please check all that apply:
2006 NLN Conference
2004 NLN Conference
2002 NLN Conference
7.
If yes, what impact did the research course have on you? (check all that apply)
Provided background for understanding lymphedema research
Resulted in the initiation of an independent or collaborative research project
Other:
8.
What types of research have you performed or collaborated on in the past? (check all that apply)
Basic science research
Clinical / Protocol-based research
Retrospective review of patient data
Case study or case series
Other:
9.
What has been your role in research to date? (check all that apply)
Primary investigator
Research assistant
Other:
10.
What are your major obstacles to performing/participating in research?
Greatest
Obstacle
Least
Obstacle
a.
Lack of knowledge of the research process
b.
Lack of time
c.
Lack of funds
d.
Insufficient patient case load
e.
Other:
11.
What types of research-focused educational sessions would benefit you most?
Greatest Benefit
Least Benefit
a.
How to do a literature review
b.
Understanding how to read and evaluate research articles
c.
How to develop a research question
d.
Understanding the various types of research which would be conducive to performing in a clinical setting
e.
How to perform clinical research in a busy clinic with limited resources (i.e. funds, time, and expertise)
f.
Writing a clinical protocol
g.
Writing a manuscript
h.
Writing a fundable grant
i.
Other:
FUTURE INTERESTS
12.
Please rate how interested you might be in future NLN sponsored educational programs that focus on
Low Interest
a.
Overview of Clinical Research Designs
b.
Review of Lymphedema Research
c.
Developing Research Ideas
d.
Writing a Clinical Protocol
e.
Funding Clinical Research in Lymphedema
f.
Grant Writing Seminar
g.
Other suggestions:
13.
Would you be interested in attending a 1-2 day workshop on understanding the research process?
Yes
No
14.
How much would you be willing to pay for an in-depth program, not including hotel and transportation?
<$100
$100-200
$200-500
I would only come if it were free
15.
Other comments
16.
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