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Pre-Advocacy Rotation Questionnaire
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1.
Resident's Contact Information
(Required.)
Name
Email Address
Phone Number
*
2.
Residency Program
(Required.)
Fort Collins FMR
North Colorado FMR
Peak Vista FMR
Saint Joseph's FMR
Sky Ridge FMR
Southern Colorado FMR
St. Anthony's FMR
St. Mary's Grand Junction FMR
Swedish FMR
University of Colorado FMR
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3.
Year of Residency
(Required.)
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?
(Required.)
2 Week Rotation
4 Week Rotation
Other rotation length and please note dates below:
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?
Yes
No
Maybe, but I would like additional information before deciding
Completing four self-paced learning modules on advocacy?
Yes
No
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.)
Yes
No
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.)
Yes
No
Maybe, but I would like additional information before deciding
6.
Please describe at least two professional benefits you hope to achieve from this Advocacy rotation.
7.
Please describe any concerns you may have about completing this Advocacy rotation.
8.
Additional Questions or Comments?
