The Impact of Nursing Home Regulations on Physician Practice - Demographic Information Please complete the Demographic Information survey below to access the course registration form. Click here if you have already submitted your demographic information. First Name: Middle Initial: Last Name: Last 4 Digits of Your Social Security Number: Email Address: Street 1: Street 2: State: Zip Code: Select Your Degree: M.D. D.O. M.S.N. Other Degree If Other, please specify: Please choose your Specialty: Family Practice General Internal Medicine Advanced Practice Nurse Other Specialty If Other, please specify: Do you have a Certificate of Added Qualification in Geriatrics? Select Yes No What is your current status?: Resident Fellow Medical Student Other If Other, please specify: Years in Practice: Percentage of Patients Over 65 years of Age: % Percentage of Practice Time in the Nursing Home: % If you experience problems with registering, check for announcements about system outages at www.umdnj.edu/webct . Get help by calling 888-465-9095 or 973-972-9832 or use our help request form.