ACOOG Mentor Volunteer Form Question Title * 1. Are you willing to serve as an ACOOG mentor to osteopathic medical students? Yes No OK Question Title * 2. Do you currently let students from COMs shadow or do rotations in your practice? Yes No Optional: Tell us more abut your rotation/shadow arrangement OK Question Title * 3. To what degree would you like to engage with the student? In Person: organized shadowing or rotations In person: lunch, coffee or other periodic meetings Remotely: Phone, email, video conferencing OK Question Title * 4. Do you actively use OMT in your practice? Yes No If yes, would you have students participate in treatment? OK Question Title * 5. Please provide contact information to be included in the student mentoring database: Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number OK DONE