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* 1. Please indicate the year you graduated from the Emory PA program.

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* 2. I am employed in: (if not currently employed skip to question #4)

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* 3. I am working as a:

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* 4. I am not employed.

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* 5. I am currently enrolled as a student

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* 6. If employed in a clinical setting, please indicate the address of your primary employer.

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* 7. Is your Practice in a Designated Medically Underserved Area (MUA) or a Health Professions Shortage Area (HPSA)? To find out, please visit http://bhpr.hrsa.gov/shortage/

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* 8. Is your main clinical practice in primary care (e.g Family Medicine, General Internal Medicine, Pediatrics)?

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* 9. My current clinical practice is in: (choose as many as apply)

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* 10. What is your current annual income? (This information is confidential and no individual information will be shared. Aggregate numbers may be used for "average salary" information in grant applications and reports.)

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* 11. May we contact you as a possible PA student preceptor?

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* 12. Would you be willing to serve as a clinical mentor for a first year PA student?

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* 13. Would you be interested in lecturing to first year PA students?

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* 14. Pleasea provide your contact information so that we can keep you informed of news and events at Emory. Also check our out website at www.emorypa.org

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