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

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

Work is underway to develop a Rural Medicine Collaborative Mentoring Network that encompasses the existing online Community of Practice. 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 completion of family medicine residency:

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* 4. 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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* 5. Do you identify as:

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* 6. Which best describes your current role?

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

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* 8. If you selected PGY3:

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