Name: _________________________________________

Affiliation: ______________________________________

Address: ____________________________________________

City, State, Zip: ______________________________________

Phone: _____________________________________________

E-mail _____________________________________________

Chapter affiliation: ____________________________________

Please describe your professional experience in working with People with Dementia?

What do you see as -3-4 critical issues the Task Force needs to address (please be as specific as possible)

From your perspective what programs do you see as “model programs” or ” best practices” Please share contact person(s)

Any additional thoughts/comments?