This questionnaire is for people that have signed up to attend the
Interventional Pain Management Cadaver Course. 
If you have not signed up, but would like to.  click here
 In order to place attendees in groups according to their level of experience,
please fill out the following MANDATORY questionnaire. Please be as accurate as possible to enhance your learning experience and to ensure appropriate group placement.
I Interventional Pain Management Cadaver Certificate Course
                    Experience Questionnaire for Group Placement

First Name          
Last Name          
Degree             
City                   
Specialty          
Email                   for SPPM use only 
Daytime Phone     
Cell Phone            for SPPM use

Please indicate your experience with the Procedures noted and Frequency
Scale of 0-5
0 none      1-2 few    3-4 several    5 many

Fellowship Trained/Pain Management yes   no 
A. Cervical Injection Techniques  
B. Lumbar Injection Techniques
C. Radiofrequency Tehcniques-Lumbar
D. Spinal Cord Stimulation
E. Percutaneous Facet Fusion
F. Lysis of Adhesions
G. Vertebroplasty
H. Atlanto Axial Injection
I. 3rd Occipital Nerve Block

Thank you for your time and attention to this questionnaire.
Attendees will be assigned to one of 10 groups. You will be required
to stay with your group as you rotate through  the procedures.
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