Pre-Advocacy Rotation Questionnaire

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* 1. Resident's Contact Information

Name

Email Address

Phone Number

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* 2. Residency Program

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* 3. Year of Residency

PGY 1

PGY 2

PGY 3

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* 4. Please select whether you want to complete a two or four week Advocacy Rotation?

2 Week Rotation

4 Week Rotation

Other rotation length and please note dates below:

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* 5. Are you interested in the following Advocacy activities?

	Yes	No	Maybe, but I would like additional information before deciding
Attending two Legislative Committee virtual meetings, held bi-weekly on Thursday evenings?	Attending two Legislative Committee virtual meetings, held bi-weekly on Thursday evenings? Yes	Attending two Legislative Committee virtual meetings, held bi-weekly on Thursday evenings? No	Attending two Legislative Committee virtual meetings, held bi-weekly on Thursday evenings? Maybe, but I would like additional information before deciding
Completing four self-paced learning modules on advocacy?	Completing four self-paced learning modules on advocacy? Yes	Completing four self-paced learning modules on advocacy? No	Completing four self-paced learning modules on advocacy? Maybe, but I would like additional information before deciding
Five week days of serving as Doctor of the Day in person at the Capitol? (They do not have to be consecutive days.)	Five week days of serving as Doctor of the Day in person at the Capitol? (They do not have to be consecutive days.) Yes	Five week days of serving as Doctor of the Day in person at the Capitol? (They do not have to be consecutive days.) No	Five week days of serving as Doctor of the Day in person at the Capitol? (They do not have to be consecutive days.) Maybe, but I would like additional information before deciding
Completing a Reflection essay on your Advocacy rotation? (i.e., What you learned during your rotation.)	Completing a Reflection essay on your Advocacy rotation? (i.e., What you learned during your rotation.) Yes	Completing a Reflection essay on your Advocacy rotation? (i.e., What you learned during your rotation.) No	Completing a Reflection essay on your Advocacy rotation? (i.e., What you learned during your rotation.) Maybe, but I would like additional information before deciding

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* 6. Please describe at least two professional benefits you hope to achieve from this Advocacy rotation.

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* 7. Please describe any concerns you may have about completing this Advocacy rotation.

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* 8. Additional Questions or Comments?