Exit this survey Physician Mentor Intake/Registration 1. Background Question Title Contact Information: Name: Titles: Email Address: Phone Number: Question Title PROFILES: Please provide us with some information on your background and interests so that we can better “match” students to your history. 1.Ethnicity: 2.Gender: 3.Generation (1st generation = immigrated as an adult; 1.5 generation = immigrated as a child; 2nd generation = born in the United States, etc.) 4.Languages Used at Work: 5.Where You Trained: 6.Current Location: 7.Specialty: 8.Practice Setting: 9.Please describe any relevant prior career experiences or interests: Question Title Please indicate the percentage of time spent in the following categories: Teaching Research Patient Care Public Health Administration Question Title Please indicate the percentage of time spent serving the general population compared to AANHPI populations (e.g. 70/30): 25% of survey complete. Next
