Teaching of Tomorrow 2012-2013, Application
Exit this survey
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1
. Full Name:
Full Name:
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2
. Discipline:
Discipline:
Family Medicine
Internal Medicine
Pediatrics
Other (please specify)
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3
. Degree:
Degree:
M.D.
D.O.
N.P.
P.A.
R.N.
M.P.H.
Ph.D.
Other (please specify)
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4
. Primary Phone Number:
Primary Phone Number:
5
. Primary Fax Number (if applicable):
Primary Fax Number (if applicable):
*
6
. Primary Email Address (please note: ALL communication for this workshop series is done via email so please list the email address that you use MOST frequently):
Primary Email Address (please note: ALL communication for this workshop series is done via email so please list the email address that you use MOST frequently):
*
7
. Academic Affiliation (Umass, UCONN, NYMC etc)
Academic Affiliation (Umass, UCONN, NYMC etc)
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8
. Who referred you for this program?
Who referred you for this program?
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9
. Practice Address/Primary practice site (include street address, city/town, state and zip code):
Practice Address/Primary practice site (include street address, city/town, state and zip code):
10
. Mailing address (if different from practice site):
Mailing address (if different from practice site):
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11
. Age:
Age:
<20
20-29
30-39
40-49
50-59
60+
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12
. Gender:
Gender:
Male
Female
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13
. Minoritiy/Disadvantaged Status:
*Underrepresented asian groups include any other than Chinese, Filipino, Thai, Korean, Japanese or Asian Indian.
**Disadvantaged means an individual who 1. comes from an environment that has inhibited the individual from obtaining the knowledge, skill and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession; or 2. comes from a family with an annual income below a level based on low income thresholds according to family size published by the U.S. Bureau of the Census, adjusted annual for changes in the Consumer Price index, and adjusted by the Secretary for use in all health professions programs (42 CFR 57.1804 c).
Minoritiy/Disadvantaged Status: *Underrepresented asian groups include any other than Chinese, Filipino, Thai, Korean, Japanese or Asian Indian. **Disadvantaged means an individual who 1. comes from an environment that has inhibited the individual from obtaining the knowledge, skill and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession; or 2. comes from a family with an annual income below a level based on low income thresholds according to family size published by the U.S. Bureau of the Census, adjusted annual for changes in the Consumer Price index, and adjusted by the Secretary for use in all health professions programs (42 CFR 57.1804 c).
American Indian/Alaskan Native
Asian, underrepresented *
Asian, NOT underrepresented
Black or African-American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White, disadvantaged**
White, NOT disadvantaged
Other (please specify)
*
14
. Years in Practice:
Years in Practice:
<3
4-10
11-20
20+
Other (please specify)
*
15
. Years in Teaching:
Years in Teaching:
<3
4-10
11-20
20+
Other (please specify)
*
16
. Student Level(s) Currently Precepted:
Student Level(s) Currently Precepted:
1st year
2nd year
3rd year
4th year
Other (please specify)
*
17
. Resident Level(s) Currently Precepted:
Resident Level(s) Currently Precepted:
1st year
2nd year
3rd year
Other (please specify)
*
18
. Practice in Underserved Areas (primary practice site):
Practice in Underserved Areas (primary practice site):
Community Health Center (section 330)
Migrant Health Center (section 329)
Health Care for the Homeless Grantees (section 340)
Publich Housing Primary Care Grantees (secion 340A)
Rural Health Clinics, federally designated (section 1861(aa)(2) of Social Security Act)
National Health Service Corps (NHSC) sites, freestanding (section 333)
Indian Health Service (IHS) or Tribal Health Sites (Pub.L. 94-437 or 93-638)
Federally Qualified Health Centers (FQHC) (section 1905(a) and (1) of SSA)
Health Professions Shortage Area (HPSA) (section 332)
Health Department, state or local
Ambulatory Practice Site, designated by state governor or serving medically underserved communities
Other (please specify)
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