1. Today's date? (Month/Day/Year)
2. What is your name? (Last, First, Middle)
3. What is your gender? Male Female
4. Your race/ethnicity? (Check all that apply.) AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN HISPANIC OR LATINO NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER WHITE
5. What is your date of birth? (Month/Day/Year)
6. What is your current address? (Street Address, City, State, Zip) (Your usual address for mailing purposes.)
Please indicate a permanent address or address of relative or friend who will know your address after graduation.
7. Name / Relationship:
8. Address: (Street Address, City, State, Zip)
9. What is the name of your school?
10. What is your program of study? Allopathic Medicine Osteopathic Medicine Nurse Anesthetists Other Advanced Practice Nurse Undergraduate Nurse Chiropractic Dental Public Health Health Administration Public Health Preventive Medicine Pharmacy Clinical Psychology Social Work Other
11. What specialty area are you studying? Please see below and enter the number here: Family Medicine General Internal Medicine General Pediatrics Physician Assistant Nurse Practitioner Nurse-Midwife General Dentistry Primary Care Podiatric Medicine
Please indicate the start and anticipated end dates of your FIRST rotation?
12. Start Date (Month/Day/Year):
13. End Date (Month/Day/Year):
14. Expected Graduation Date (Month/Year):
15. Preceptor Name / Degree:
16. Physician's Name (if not preceptor):
18. What is the probability that you will eventually practice in a rural area? Not Very Probable Somewhat Probable Highly Probable Haven't Thought About It
19. What is the probability that you will eventually practice in an under served area? Not Very Probable Somewhat Probable Highly Probable Haven't Thought About It
20. Prior or contractual commitments? Not Important Somewhat Important Very Important Don't Know
21. Serving needy populations? Not Important Somewhat Important Very Important Don't Know
22. Rural life-style? Not Important Somewhat Important Very Important Don't Know
23. Urban life-style? Not Important Somewhat Important Very Important Don't Know
24. Opportunities for professional development? Not Important Somewhat Important Very Important Don't Know
25. Earning opportunities? Not Important Somewhat Important Very Important Don't Know
26. Family or personal commitment? Not Important Somewhat Important Very Important Don't Know
28. Are you currently enrolled or participating in any state sponsored loan repayment program? Yes No
29. Your email address? (Required for online submission)