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SOARNet Member Enrollment Form

Please complete the form below to become a SOARNet member.

The Supporting Older Adults through Research (SOARNet), is an older adult-focused Practice-Based Research Network (PBRN). SOARNet represents a collaboration between the University of Texas Health Science Center San Antonio and community partners.

The SOARNet mission is to develop and conduct practice-based research to improve the health of older adults. The goal of the SOARNet PBRN is to generate practical and timely evidence that can be used by primary care providers to enhance the quality and efficacy of older adult health care.

Why become a member? SOARNet is a space for practitioners who are interested in learning about, supporting, and/or leading research to support older adult patients and their families. Our PBRN leadership and Advisory Board offer our expertise and perspectives to help you brainstorm ideas for research, prepare and submit proposals for funding, and connect with other likeminded individuals who are invested in improving patient care in our communities.

If you have any questions, comments, or thoughts to share with our team, please contact our Research Coordinator: Caitlin Sangdahl (sangdahl@uthscsa.edu).

First Name:

* must provide value

Last Name:

* must provide value

E-mail address:

* must provide value

Phone Number:

* must provide value

Year of Birth:

Gender:

Male

Female

Non-binary

Prefer to self-describe

Prefer not to answer

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Describe Gender:

Race:

White

Black or African American

Multi-racial

Other or prefer to self-describe

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Describe Race:

Ethnicity:

American Indian or Alaska Native

Arab, or Arab American

Asian, Asian American

Hispanic or Latino

Native Hawaiian or Pacific Islander

Other or prefer to self-describe

Describe Ethnicity:

Which of the following best describes you?

* must provide value

Healthcare Provider

Community Organization

Community Member

Researcher

Other

Please Describe:

Community Organization Information

Please provide other information as available.

What Community Organization are you apart of?

* must provide value

WellMed Charitable Foundation

Metropolitan Health District - City of San Antonio

South Texas Area Health Education Center Program (ST-AHEC)

Gonzaba Foundation

Methodist Healthcare Ministries

Alzheimer's Association

Other

Please Describe:

What is/are your population(s) of focus?

Older adults

People living with dementia

Caregivers

Chronically ill/disabled

Homebound older adults

Unhoused older adults

Families

Victims of elder abuse

Other

Please Describe:

Please briefly describe the services your organization provides:

Food access

Legal

Housing

Transportation

Education

Care

Other

Please Describe:

Community Member Information

Please provide other information as available.

Which of the following best describes you:

I am an older adult

I am caring for an older adult

I am a Community Health Worker (or promotor/a)

I am a community service provider/advocate

I am a student

Other

What institution are you affiliated with?

* must provide value

UT Health San Antonio

University of Texas San Antonio (UTSA)

University of Incarnate Word (UIW)

Texas A&M University - San Antonio

Trinity University

St. Mary's University

Our Lady of the Lake University

Other

Please Describe:

How long have you been caring for an older adult?

Please Describe:

Research Background Information

Please provide other information as available.

With which institution(s) are you affiliated?

* must provide value

UT Health San Antonio

University of Texas San Antonio

University of Incarnate Word (UIW)

Texas A&M University - San Antonio

Trinity University

St. Mary's University

Our Lady of the Lake University

Other

Describe Other:

Which of the following best describes the research you perform?

Basic science

Clinical

Public Health

Dissemination and Implimentation Science

Community-Engaged

Other

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Please Describe:

Practice Information

Please provide other information as available.

Do you practice full-time or part-time?

Full-time (32 or more hours per week)

Part-time (less than 32 hours per week)

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Name of Practice:

* must provide value

Address of Practice:

* must provide value

City:

* must provide value

State:

* must provide value

Zip Code:

* must provide value

Phone Number:

Practice email:

Website:

Type of community served by your practice:

Rural

Urban

Suburban

Patient Characteristics

Please tell us about your patient population. Approximate if necessary. Please total 100%

In this section, please describe the age breakdown for your patients.

What % of your patients are 18-45 years old?

What % of your patients are 46 to 65 years old?

What % of your patients are older than 66?

Please tell us about your patient population.

In this section, please provide information regarding the Racial/Ethnic make-up of your patients.

Race:

White

Black

Multi-racial

Other or prefer to self describe

Please describe:

Ethnicity:

American Indian or Alaska Native

Arab, or Arab American

Asian, Asian American

Hispanic or Latino

Native Hawaiian or Pacific Islander

Other or prefer to self describe

Please describe:

Please tell us about your patient population. Approximate if necessary. Please total 100%

In this section, please approximate the percentage of patients paying with the following methods.

% Medicare:

% Medicaid:

% Private Insurance:

% No insurance (self-pay):

% Other methods:

Please tell us about your patient population. Approximate if necessary. Please total 100%.

In this section, please provide information on your patient visit types.

% Attending only in an emergency:

% As Needed:

% Attending regularly:

How involved would you like to be in the network?

* must provide value

Full participation: Receive newsletters/correspondence AND participate in surveys/questionnaires AND participate in research.

Limited participation: Receive newsletters/correspondence AND participate in surveys/questionnaires.

Informational: Receive newsletters/correspondence only.

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Would you be interested in joining the Advisory Board at a future date?

* must provide value

Yes

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