The Partners in Care Study Instruments

*First Name:

Middle Name:

*Last Name(s) or Family name:

*Organization:

*Email Address:

*Telephone Number:

Fax Number:

*Address 1:

Address 2:

*City:

*State/Province:

*Zip Code/Postal Code:

*Country:

What type of organization do you work for?

Academic
Government
Non-profit research institute
For-profit research institute
Non-profit service provider
Other, please specify:

What is your primary role in this organization?

Faculty, Principal Investigator, Project Leader, Research Investigator
Research Associate
Graduate Student
College Student
Other Student
Programmer, Data Manager
Data Librarian
Support Staff
Other, please specify:

What is the highest degree that you have completed?

Associates or AA
Bachelor's
Master's
PhD, DSc, or equivalent degree
MD
Other

In using these data files, are you working on your own, are you a co-author or collaborator or are you working under the direction of someone else?

On my own
Co-author or collaborating with others
Under the direction of someone else

If you are working under the direction of someone else, please provide the name, email address, phone number, and mailing address of the principal investigator on this project:

Please select your primary research area(s):

Anthropology
Demography
Economics
Epidemiology
Gerontology
Health Services
Political Science
Psychology
Public Policy
Social Aspects of Health
Social Work
Sociology
Other, please specify:

By clicking on the "Register" button, you are agreeing to comply with the terms and conditions in the:
Use Agreement for the Partners in Care Public Use data.