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1. Demographics

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* 1. Name:

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* 2. Current Job Title:

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* 3. Department/Institution Name:

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* 4. E-Mail Address:

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* 5. How long have you been in your role?

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* 6. Please select your gender identity.

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* 7. Please select your ethnicity.

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* 8. Please select your racial identity. Please select all that apply.

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* 9. If American Indian or Alaska native, or Asian were selected, please specify:

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* 10. How many clinical Faculty are in your department?

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* 11. Describe your department setting.

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* 12. Is your institution public or private?

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* 13. How many students were in the most recent entering class at your school of medicine?

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* 14. How many research intensive faculty (PhD, MD, or equivalent) are in your department?

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* 15. Annual clinical revenue

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* 16. Annual research related funding

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* 17. Does your department have divisions that report up to the department?

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* 18. If yes, what is their administrative structure?

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* 19. How many fellowship program(s) exists in your department?

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* 20. Please list your fellowships:

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* 21. How many residency program(s) exists in your department?

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* 22. How many total residents do you have annually?

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* 23. How many ambulatory clinics exist in your department?

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* 24. Which of the following clinical areas/services does your department provide?

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* 25. Do you partner with any FQHCs?

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* 26. If yes, how do you partner?

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* 27. Are you interested in:

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