JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
ADFM Administrators' Mentorship Program: Demographics form
Sign in to Google
to save your progress.
Learn more
Name:
Your answer
What is your job title?
Your answer
How long have you been in your current position?
Your answer
How long have you been a member of ADFM?
Your answer
What is the full name of your medical school?
Your answer
What is the name of your department? (if you are a division of Family Medicine, indicate the name of the department you are part of)
Your answer
Is your institution public or private?
public
private
Clear selection
Describe your department setting:
check one
Allopathic medical school (MD)
Osteopathic medical school (DO)
Regional medical center (e.g., stand-alone program)
Other:
Clear selection
How many salaried faculty are in your department? (i.e. do not include volunteer faculty)
Your answer
How many staff are in your department?
Your answer
Education
How many residency programs are part of your department and/or affiliated with your department? (please describe)
Your answer
Please list any fellowships your department has, if ACGME or non-ACGME, and # of fellows
Your answer
Do any of these elements exist under the umbrella of your department?
PA program
sports medicine
palliative care
geriatrics
public health division
Other:
Financial
What is the total revenue for your department for the last fiscal year?
Your answer
What is the total restricted revenue for your department for the last fiscal year?
Your answer
Other
Is there anything else we need to know about your department in order to more closely match you with a mentor/mentee?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
