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* 1. Please provide your full name:

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* 2. I am a ...

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* 3. Please provide the name of your school/college/university:

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* 4. During what semester/term did you complete your rotation?

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* 5. What was the start date and end date of your rotation?

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* 6. How many rotation hours did you complete with Fairfield Community Health Center?

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* 7. I affirm that I have completed the OPCWI post-rotation survey.

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* 8. Please upload a screen shot of your post-survey confirmation email:

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* 9. If I meet the minimum qualifications for an open position at Fairfield Community Health Center (FCHC), I would like to be considered for employment by FCHC in the future.

(If you select yes, you may be contacted by personal e-mail or phone if you meet qualifications for an open position)

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