Exit this survey

* 1. Full Name:

* 2. Discipline:

* 3. Degree:

* 4. Primary Phone Number:

5. 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):

* 7. Academic Affiliation (Umass, UCONN, NYMC etc)

* 8. Who referred you for this program?

* 9. Practice Address/Primary practice site (include street address, city/town, state and zip code):

10. Mailing address (if different from practice site):

* 11. Age:

* 12. Gender:

* 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).

* 14. Years in Practice:

* 15. Years in Teaching:

* 16. Student Level(s) Currently Precepted:

* 17. Resident Level(s) Currently Precepted:

* 18. Practice in Underserved Areas (primary practice site):