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Post-Rotation Survey
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1.
Please provide your full name:
(Required.)
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2.
I am a ...
(Required.)
Medical Student
Physician Assistant Student
APRN student
Behavioral Health Student
Medical Assistant Student
Other (please specify):
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3.
Please provide the name of your school/college/university:
(Required.)
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4.
During what semester/term did you complete your rotation?
(Required.)
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5.
What was the start date and end date of your rotation?
(Required.)
Start Date (MM/DD/YYYY):
End Date (MM/DD/YYYY):
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6.
How many rotation hours did you complete with Fairfield Community Health Center?
(Required.)
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7.
Who did you precept with?
(Required.)
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8.
I affirm that I have completed the
OPCWI post-rotation survey
.
(Required.)
I have completed the survey.
I have not completed the survey.
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9.
Please upload a screen shot of your post-survey confirmation email:
(Required.)
Do not attach your individual answers to post-survey questions. Your survey answers are private and will not be shared with Fairfield Community Health Center
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