AHEC Rotation Questionaire Survey

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1. Please provide the following information:

Please provide the following information: Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Country (not USA):
Email Address:
Phone Number:

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2. Gender

Gender Male

Female

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3. Ethnicity

Ethnicity Hispanic

Non Hispanic

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4. Race (select all that apply)

Race (select all that apply) African American / Black

American lndian/Alaskan Native

Asian (Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai)

Asian (Other)

Native Hawaiian/Other Pacific Islander

White Disadvantaged (educationally or economically)

White Non-Disadvantaged

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5. In what institution are you currently enrolled?

In what institution are you currently enrolled?

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6. Hometown at time of high school graduation (City/State)

Hometown at time of high school graduation (City/State)

7. College Attended (include City/State)

College Attended (include City/State)

8. Undergraduate Major

Undergraduate Major

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9. In which kind of community did you grow up? (Select one)

In which kind of community did you grow up? (Select one) Urban/Inner City

Suburban

Rural

Frontier

10. Currently in which Educational Level

Currently in which Educational Level Certificate

Associate's

Bachelors

Masters

Doctoral

Other (please specify)

11. Currently which Education Status

Currently which Education Status Student, Pre-Health Professions Program

Student, Enrolled in Any Health Professions Program

Intern

Resident

Fellow

Other (please specify)

12. Anticipated Date of Graduation

	MM		DD		YYYY
Date:	Anticipated Date of Graduation Date: Month	/	Day	/	Year

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13. Health Profession Discipline (Select only one)

Health Profession Discipline (Select only one) Chiropractic

Community Health Worker

Dental Hygienist

Dentist, General

Dietitian/ Nutritionist

First Responder (EMT, Paramedic, Fire Rescue, HazMat)

Marriage and Family Therapist

Nurse (Licensed/Practical)

Nurse (Registered)

Nurse Midwife

Nurse Practitioner

Occupational Health Specialist/Therapist

Optometrist

Pharmacist

Physical Therapist

Physician, Allopathic Medicine

Physician, Osteopathic Medicine

Physician Assistant

Podiatrist

Professional Counselor

Psychiatrist

Psychologist

Public Health Specialist (lncl. Public Health Nurse)

Social Worker

Veterinarian

unknown

Allied Health / other (specify)

14. Parent/guardian information (optional):

Parent/guardian information (optional): Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Phone Number:

15. What type of community would you like to work? (select all that apply)

What type of community would you like to work? (select all that apply) Rural

Frontier

Urban/Inner City

Suburban

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16. l intend/plan/would like to enter a health career in primary care (such as Family Medicine, General Internal Medicine, General Pediatrics, nurse practitioner, or physician assistant, etc.).

l intend/plan/would like to enter a health career in primary care (such as Family Medicine, General Internal Medicine, General Pediatrics, nurse practitioner, or physician assistant, etc.). Yes

No

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17. I intend/plan/would like to work with people who are medically underserved or where there is not enough healthcare

I intend/plan/would like to work with people who are medically underserved or where there is not enough healthcare Yes

No

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18. I intend/plan/would like to work in rural areas (not big cities)

I intend/plan/would like to work in rural areas (not big cities) Yes

No