1. NAME: Title Last Name First Name Middle Name

Email (Required for online submission)

2. What is the ZIP Code of the town from which you graduated high school?:

3. What is the name of the facility where your rotation took place?:

Name of facility

City

4. How much clinical time did you spend at this site? (If less than 1 day enter “1”.):
Days

Start date of this rotation:
Month Day Year

End date of this rotation:
Month Day Year

5. Has the clinical rotation you just completed influenced your feelings about the probability that you might practice in one of the following areas upon graduation? (Please answer all.)

In Pennsylvania Made It less Likely No Influence Made it More Likely
In a rural area Made It less Likely No Influence Made it More Likely
In an inner-city area Made It less Likely No Influence Made it More Likely
In a medically underserved area Made It less Likely No Influence Made it More Likely

6. What is the name of your residency program?:

7. Do you consider yourself a minority race in the United States? Yes No Don’t know or would prefer Not to answer

Enter the below form code (all numbers)