Medical Student Rotation Mentor Interest Survey

Thank you for your interest in serving as a mentor for the Conquer Cancer Foundation of ASCO Medical Student Rotation for Underrepresented Populations (MSR).

The MSR provides a minimum 4-week mentored clinical or clinical research oncology rotations for U.S. medical students from populations underrepresented in medicine who are interested in pursuing oncology as a career.

Please note that matches are made based on recipient preferences (i.e., location, rotation setting, oncology interest). If we are unable to match you with a medical student, your name will remain in our database for future reference.

Visit asco.org/MSR for more information about the program.

Questions? Email grants@conquer.org.

Question Title

* 1. Please enter your contact information:

Name

Institution / Practice

Address 1

Address 2

City

State

Zip

Phone Number

Email Address

Question Title

* 2. How did you hear about this mentoring opportunity? (Select all that apply.)

ASCO Annual Meeting

Conquer Cancer website

Other, please specify

Question Title

* 3. Are you currently an ASCO member?

Yes

Question Title

* 4. Please specify your specialty area:

General Oncology

Geriatric Oncology

Gynecologic Oncology

Hematology Oncology

Pediatric Oncology

Radiation Oncology

Surgical Oncology

Other, please specify

Question Title

* 5. Please specify the type of rotation you would be able to provide. (Check all that apply; Examples of the two types of rotation settings can be found in the Request for Applications on the Conquer Cancer website here: CONQUER.ORG/MSR.)

Clinical Cancer Research Rotation (A rotation in a clinical cancer research setting will provide students with hands-on laboratory research experience supervised by the mentor.)

Patient Cancer Care Rotation (A rotation in a patient cancer care setting, whether outpatient or inpatient, provides hands-on exposure to the treatment and management of patients.)