The following survey provides essential information for the Augusta Webster Office of Medical Education.

If you give your permission, the information gathered by this survey, along with your basic demographic data (First Name, Last Name, Home state, Undergraduate Institution, Undergraduate major(s) and/or minors(s), and Age), will be used to organize several educational experiences for you.

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* 1. What is your last name?

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* 2. What is your first name?

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* 3. As part of Feinberg’s Society structure, each incoming M1 student is matched with a M2 student from their society, who serves as their Big Sib. In order to pair up the students, the student committee is requesting access to the following information – your First Name, Last Name, Home state, Undergraduate Institution, Undergraduate major(s) and/or minors(s), and Age. This information is protected by the Family Education Rights and Privacy Act (FERPA). If you would like to share this information with the committee of second year students making Big Sib-Little Sib assignments, you must give your consent by clicking "Yes" to the FERPA Release item below. If you choose not to release the FERPA-protected information, you will still be paired with a second year student.

By selecting "Yes" I give my consent for the Feinberg School of Medicine's Augusta Webster Office of Medical Education to release the following non-public information to the Big Sib-Little Sib student committee for the purpose of pairing me with a second year student. Information that will be shared includes my: First Name, Last Name, Age, Home City, Home State, Home Country, Undergraduate Academic Institution(s) Attended, Majors and Minors. I also understand that I can change this decision at any time by contacting the Augusta Webster Office of Medical Education. * If you have any questions, please contact Allison Matricaria allison.matricaria@northwestern.edu 

FERPA Release:

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* 4. Are you planning on pursuing a dual degree?

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* 5. If yes or maybe, please indicate the degrees in which you are interested

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* 6. Would you like to be assigned to a college that provides you opportunities to participate in enhanced public health experiences? (Please note: This is required for students entering the dual degree MD/MPH program and most appropriate for students with a strong interest in public health.)

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* 7. For early clinical training most students are placed in a primary care office or hospital setting with a family medicine or internal medicine physician however we have a few pediatric sites. Would you be interested in a pediatric site for your Phase 1 clinical placement (ECMH/IP)?

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* 8. Following questions ask about additional languages and Proficiency. Please indicate your language proficiency level for: SPANISH ILR_scale

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* 9. Please indicate your language proficiency level for: MANDARIN  ILR_scale

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* 10. Please indicate your language proficiency level for: RUSSIAN  ILR_scale

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* 11. Please indicate your language proficiency level for: POLISH  ILR_scale

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* 12. Please indicate any additional languages and  proficiency level below:

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* 13. Please indicate your language proficiency level ILR_scale 

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