Learner Registration Form for SETxGWEP Fall Risk Training

Today's Date

In a few words, describe the SETxGWEP training or activity you are interested in?*

Please choose the best description of your organization.*

Academic Institution

Clinical Provider

Community-based Organization

Department of Veterans Affairs (VA)

What kind of learners are you seeking to train or educate with this learning activity?*

Please choose as many options as are relevant for this specific learning activity.

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From what discipline do your learners come?*

Please choose as many options as are relevant for your intended learners.

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Who is the best point of contact for these learners?*

Please give the name of the person to follow up with to organize logistical details?

Point of Contact Email*

Please provide the preferred email address of the contact for follow-up.

Start Date*

When do you wish to begin providing the education to your learners?

Is this a fixed date or is it flexible?*

Fixed

Flexible

End Date

If there is a finite window to offer the education, please enter when the education must be concluded.

About how many learners do you expect to engage in this training at this time?*

Ballpark estimate is sufficient.

In follow-up communications, how should we call the group of learners for this current training opportunity?*

E.g. 3rd year dental residents; Fall 2021 Geriatric Social Work students

If you have an idea of how to distribute the educational content to your learners, please pick the best option below.*

If you are unsure, please select that option.

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Progress/Next Steps

If there is any info you wish to share about coordinating next steps for the learning activity, please add it below.

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