Demographic Survey

Before you can proceed with your online renewal, the Nevada State Health Division, in collaboration with the University of Nevada School of Medicine, Nevada Medicaid and the Nevada Office of Rural Health, is asking that you complete the following brief survey in order to gain a better understanding of the health care workforce in Nevada. Participation assures policy makers and legislators have accurate and timely information that can be used to analyze the health care provider workforce and guide policy development. The workforce data will not be released to any person or agency other than those few people who need the data to perform their workforce analysis. Once you have completed the survey, you will be allowed to proceed with the renewal process.

We know that your time is valuable.  By coordinating our efforts with the Board of Medical Examiners, we hope to reduce the need for individual calls to each and every practice in the state, which depletes the state’s limited resources, as well as yours.
 

We greatly appreciate your assistance!
*Name of Licensee:  
     
*Type of License:   MD   PA  RT Clinical  RT Management
     
Age:  
     
Primary Practice Address: (Please do not indicate your home address – if no practice address please put “n/a”)
 Address:  
City:  
Zip:
     
Number of hours per week in direct patient care:  
     
Specialty:
(Please select one)
Family Practice
General Practitioner
Internal Medicine
Pediatrician
OB/GYN
Geriatrics
Psychiatry
Other MD 
Practitioner of Respiratory Care
   
Majority of medical practice is in:
(Please select one)
Direct Patient Care
Administration
Research
Teaching/Education
Retired
Non-patient activities or other
   
Percentage of medical practice Medicaid?: %
     
Percentage of medical practice Medicare?: %
     
Are you accepting new patients? Yes  No  N/A
     
How much longer do you anticipate practicing medicine in Nevada?:

<5 years    6-10 years   11-15 years   >16 years

     

Please provide office contact information in case clarification is needed:

Office Manager's Name:
Phone:  
Email Address:  
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