Full Name Address City State Zip Specialty Phone Email

1. How many years have you been in practice?

1-5 6-10 11-15 16+

2. Please describe your practice (check all that apply):

Solo   Academic of Hospital Affiliation   Group   Private Practice

3. Please describe the location of your practice (check all that apply):

Suburban   Major Metropolitan Area   Rural   Underserved Region

4. What percentage of your patients are ?

Caucasian African American(not of Hispanic origin) Hispanic Asian or Pacific Islander Native American or Alaskan Native

5. Do you teach residents or fellows ?

Yes No

6. Please identify the number of nurse practitioners or physician assistants working in your practice

PA's  NP's

7. How many patients do you see per week?

8. What percentage of your patients have a diagnosis of :

Renal Cell Carcinoma Prostate Cancer

9. How many hours of oncology-related CME activities have you completed over the last 3 years?

0-10 11-25 26-50 50+

10. Do you have wireless internet access where you see patients?

Yes No

11. Please indicate which of the following devices you currently use or have used in the past:

iPhone   Samsung Blackjack   Blackberry   Palm PDA   iPod Touch   Trio   Other

12. Please indicate which of the following online medical resources you use or have used regularly :

Epocrates PubMed Medscape Google Scholar Medpage Other

In order to participate in this program, attendance at the live CME meeting Genitourinary Oncology Update: Renal Cell and Prostate on July 31, 2010 at Mount Sinai Medical Center, NY is required. Are you able to attend this CME activity?

Yes No