Leadership Day Funding Form Survey

Question Title

* 1. Please enter your contact information below (address listed below will apply as voting district)

Name

ACP ID

Mailing Address

Mailing Address 2

Mailing Address City/Town

Mailing Address State/Province

Mailing ZIP/Postal Code

Email Address

Cell Phone Number

Question Title

* 2. What is your membership with ACP?

Student Member

Resident/Fellow Member

Member

FACP

MACP

Affiliate

Question Title

* 3. Which medical school are you part of?

Baylor College of Medicine

TCU and UNTHSC School of Medicine

Texas A&M Health Science Center College of Medicine

Texas Tech University Health Sciences Center Paul L. Foster School of Medicine

Texas Tech University Health Sciences Center School of Medicine (Lubbock)

The Joe R. and Teresa Lozano Long University of Texas School of Medicine at San Antonio

University of Houston - College of Medicine

University of the Incarnate Word School of Osteopathic Medicine

University of North Texas Health Science Center at Fort Worth Texas College of Osteopathic Medicine

The University of Texas at Austin - Dell School of Medicine

The University of Texas Health Science Center at Houston McGovern Medical School

The University of Texas Medical Branch School of Medicine (Galveston)

The University of Texas Rio Grande Valley School of Medicine

The University of Texas Southwestern Medical Center at Dallas Southwestern Medical School

Other (please specify)

Question Title

* 4. Which residency program are you part of?

Baylor College of Medicine Internal Medicine Residency Program

Baylor University Medical Center Program

Corpus Christi Medical Center's Graduate Medical Education's Internal Medicine Program

HCA Gulf Coast Education Consortium Program

Houston Methodist Internal Medicine Residency

Las Palmas Del Sol Healthcare Program

Medical City North Texas Consortium Graduate Medical Education (Fort Worth)

Medical City North Texas Consortium Graduate Medical Education (Weatherford)

Methodist Health System Internal Medicine Residency Program

San Antonio Uniformed Services Health Education Consortium Program

Texas A&M Health Science Center College of Medicine - Scott & White Internal Medicine Residency (Round Rock)

Texas A&M Health Science Center College of Medicine - Scott & White Internal Medicine Residency (Temple)

Texas Health Presbyterian Dallas. Internal Medicine Residency Program

Texas Institute for Graduate Medical Education and Research (TIGMER) Program

Texas Tech University Health Science Center At Amarillo - Internal Medicine Residency Program

Texas Tech University Health Science Center At El Paso - Internal Medicine Residency Program

Texas Tech University Health Science Center At Lubbock - Internal Medicine Residency Program

Texas Tech University Health Science Center At Permian Basin- Internal Medicine Residency Program

University of Texas at Austin Dell Medical School - Internal Medicine Residency

University of Texas Health Science Center at Tyler/CHRISTUS Good Shepherd Medical Center Program

UT Health San Antonio - Internal Medicine Residency Program

UT Southwestern Medical Center Internal Medicine Residency Program

UTHealth Science Center at Tyler

UTHealth Internal Medicine Residency Program

UTMB Internal Medicine Residency Program

UTRGV Internal Medicine Residency at Doctors Hospital at Renaissance

UTRGV Internal Medicine Residency at Valley Baptist Medical Center

William Beaumont Army Medical Center Program

Other (please specify)

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* 5. Do you have experience in advocacy?

Yes

Question Title

* 6. If yes, please describe.

Question Title

* 7. Have you registered for Leadership Day?

Yes

Question Title

* 8. I agree that I am a first time attending physician, student, or resident/fellow member

I agree