1. Today's date? (Month/Day/Year)

2. What is your name? (Last, First, Middle)

3. What is your gender? Male Female

4. Has your last name changed since entering AHEC rotations?  Yes No If yes, former last name:

5. Has your permanent address changed since entering AHEC rotations? Yes No If yes, new permanent address? (Street Address, City, State, Zip)

6. Probability that you will eventually practice in Pennsylvania? No Influence Made it More Likely Made it Less Likely

7. Probability that you will eventually practice in a rural area? No Influence Made it More Likely Made it Less Likely

8. Probability that you will eventually practice in an under served area? No Influence Made it More Likely Made it Less Likely

9. My preceptor or trainer: Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied No Opinion Doesn't Apply

10. How much I learned: Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied No Opinion Doesn't Apply

11. My living arrangements: Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied No Opinion Doesn't Apply

13. Rotation End date (Month/Day/Year):  

14. Please indicate the total number of days of clinical experience you have just completed:

15. Are you a medical student? Yes No

16. Preceptor Name / Degree:

17. Physician's Name (if not preceptor):

Name and location where your rotation took place:

18. Facility Name:

19. Facility Address: (Street Address, City, State, Zip)

20. What type of rotation was it? First year Second year Third year Fourth year Internship Residency Practice Other

21. Your email address? (Required for online submission)

22. Comments