1. Rotation Information

* 1. Please fill out the following information:

* 2. Rotation Dates:

Start Date:
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Finish Date:
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* 3. University:

* 4. Program:

* 5. Level of Training:

* 6. Year in Program:

* 7. Which community choice did you receive?

* 8. Please identify your main reason(s) for participating in a ROMP-facilitated rotation:

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