AHEC Rotation Questionaire

 
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1. Please provide the following information:
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2. Gender
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3. Ethnicity
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4. Race (select all that apply)
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5. In what institution are you currently enrolled?
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6. Hometown at time of high school graduation (City/State)
7. College Attended (include City/State)
8. Undergraduate Major
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9. In which kind of community did you grow up? (Select one)
10. Currently in which Educational Level
11. Currently which Education Status
12. Anticipated Date of Graduation
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Date:
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13. Health Profession Discipline (Select only one)
14. Parent/guardian information (optional):
15. What type of community would you like to work? (select all that apply)
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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.).
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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
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18. I intend/plan/would like to work in rural areas (not big cities)