Student Mentee Intake/Registration

1. Background

Background: The National Council of Asian Pacific Islander Physician’s “Student Community Engagement Program” (SCEP) is designed to increase awareness of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) health issues and increase the engagement of AANHPI students and trainees in service to our communities.
It is our goal to bring together AANHPI students who are committed to learning about how they can effect positive change in the health and well being of our communities and link them with doctors who will be able to guide them through the process.
This survey is the first step in the SCEP and will provide the information we need to best match you according to your individual goals and interests.

Question Title

Contact Information:

Name:

Titles:

Email Address:

Phone Number:

Question Title

PROFILES: Please provide us with some information on your background and interests so that we can better “match” physicians to your history.

1.Ethnicity:

2.Gender:

3.Generation (1st generation = immigrated as an adult; 1.5 generation = immigrated as a child; 2nd generation = born in the United States, etc.)

4.Languages Spoken:

5.Medical/Professional school:

Class of:

6.Current Location:

7.Career interests in clinical medicine practice(e.g. specialty, future work setting):

8.Non-clinical interests(e.g. public health, research, administration, teaching, projects):

9.Desired outcomes from this community engagement opportunity:

Please include a resume, CV, or brief description of your history including, but not limited to, academic background, extracurricular interests, skills, technological capabilities and proficiency.

Resumes should be sent to David Hawks (dhawks@ncapip.org) and Barbara Cardinal (bcardinal@ncapip.org)

25% of survey complete.