EMS Scholarship Qualifying Questionnaire 2013 Comprehensive Update: Stroke and Neurocritical Care

Prefix Mr. Mrs. Miss Ms. Dr. Prof

First Name

Middle Name

Last Name Credentials/Certifications

(ex. EMT, EMT-P, etc.) Email (REQUIRED) * An account will be created for you on The Ohio State University Center for Continuing Medical Education website (http://ccme.osu.edu). An electronic record of your CME certificate for this conference will maintained up to six years. You will log on to this website to retrieve your CME certificate. Address 1

Address 2

City State

Zip Country

Phone ( ) Fax ( ) Job Classification/Title (ex. EMS Coordinator,

Teaching Captain, Firefighter, etc) EMS Agency (ex. department, station number, etc.)

What population/area do you serve?

Briefly describe why you feel you should be selected to receive this scholarship? (Maximum of 200 words)

EMS Scholarship Qualifying Questionnaire (cont.)

If I am chosen for the scholarship, I plan to attend:

Full Conference (Oct 10 & 11) Thursday ONLY (Oct 10) Friday ONLY (Oct 11)

For planning purposes, if you plan to attend the conference on Friday, October 11, please select ONE talk from each Concurrent Session below:

Concurrent Session Selection (PLEASE SELECT ONE FROM EACH SECTION BELOW)

Concurrent Session #1 A – Intravenous Thrombolysis: Beyond NINDS B – Stroke and Hemicraniectomy C – Stroke Rehabilitation IP and after Discharge I will not be attending this concurrent session.

Concurrent Session #2 A – Update in the Management of Intracerebral Hemorrhage B – Update in Stroke Prevention C – Stroke Mimics I will not be attending this concurrent session.

Concurrent Session #3 A – Childhood Stroke B – Update in the Surgical Management of Intracranial and Extracranial Vascular Stenosis and Dissection C – Hospital Stroke Certifications I will not be attending this concurrent session.

Concurrent Session #4 A – Women and Stroke/Stroke in Pregnancy B – Cryptogenic Stroke C – Update in the Management of Subarachnoid Hemorrhage I will not be attending this concurrent session.

Concurrent Session #5 A – Telemedicine and Stroke B – Spasticity Options in Stroke Care C – New Drugs Impacting Stroke Patients I will not be attending this concurrent session.