RUSM Chief Resident/Fellow Survey

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* 1. CONTACT INFORMATION

First Name:

Middle Initial:

Last Name:

Last Name (if different at time of at time of graduation):

Graduation Year:

Preferred Phone Number:

Preferred Email Address:

Street Address 1:

Street Address 2:

City:

State/Province:

Zip Code:

Country:

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* 2. CHIEF RESIDENT OR FELLOW?

Chief

Fellow

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* 3. RESIDENCY/FELLOWSHIP PROGRAM/HOSPITAL

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* 4. RESIDENCY/FELLOWSHIP CITY

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* 5. RESIDENCY/FELLOWSHIP STATE/PROVINCE

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* 6. RESIDENCY/FELLOWSHIP SPECIALTY

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* 7. CHIEF RESIDENT/FELLOWSHIP YEAR OF TENURE (ie. 2021-2022)