This survey serves as your online application to join the Rural Medicine Initiative Network.

To participate in this Network, you must be a Family Physician or Resident practicing in the province of Ontario.

The survey collects demographic information about you and your practice as well as your learning needs for continuing medical education.

Later in this survey, you will have the opportunity to indicate your interest in joining the Rural Medicine Initiative Collaborative Mentoring Network as a Mentor or Mentee, or participating in the Community of Practice only.

The information you provide will help shape future program development. Thank you in advance for your participation.
About You

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* 1. Full name:

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* 2. Active email address which you regularly check:

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* 3. Your year of birth: **This information is collected for program evaluation and research purposes, as well as consistent data collection across the Networks.

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* 4. Years in practice:

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* 5. Do you identify as:

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* 6. Which best describes your current role?

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* 7. Please provide your CPSO number (if applicable):

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* 8. If you are a resident in family medicine please indicate your level of training:

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* 9. If you selected PGY3:

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