| *1.
Please enter today's date |
|
| *2.
Last Name, First Name |
|
| *3.
Your birth date |
(e.g.
04/21/2004) |
| *4.
Enter the last 4 digits of your SSN |
|
| *5.
Enter your email address |
|
| *6.
Your current/local address |
City
State
Zip
|
| *7.
Please enter your home phone number |
(XXX-XXX-XXXX
for all phone numbers) |
| 8. Please enter your work phone number |
|
| 9. Please enter your
cell phone number |
|
| *10.
Please enter your permanent/parental address |
City
State
Zip
County
|
| 11. Please enter your
permanent/parental phone |
|
| *12.
Emergency contact |
|
| *13.
Emergency contact person phone number |
|
| *14.
Please select one race /ethnicity from list |
|
| *15.Classify
the area where you grew up |
|
| *16.Gender & Marital Status |
Previous Names:
|
| *17.
Please select the University you are attending |
Clemson
Francis Marion / MUSC
MUSC
SCSU
USC
Winthrop
Other, please specify:
|
*18. Please select your discipline |
Dental
Health Administration
Medicine
RN
APN / CNS
Nurse Midwife
OT
Pharmacy
PT
PA
Public Health
Social Work
Speech Pathology
Nutrition
Other, please specify:
|
|
*19. Please select the training year
of your degree: |
|
| *20.
Are you receiving federal education assistance money? |
Yes
No
|
| 21.
If yes to #20, please specify |
|
| *22.
Are you active military? |
Yes
No
|
| *23.
Select your first choice of session |
Lowcountry
Pee Dee
Mid-Carolina
Upstate
|
| 24. Select your second choice
of session |
Lowcountry
Pee Dee
Mid-Carolina
Upstate
|
| 25. Select
your third choice of session |
Lowcountry
Pee Dee
Mid-Carolina
Upstate
|
| *26.
Please enter your course number |
|
| *27.
Please enter your Coarse/Rotation Title |
|
| *28.
Do you have access to rural housing during this rotation? |
Yes
No
|
| *29.Do
you already know a preceptor who may be willing to precept you? |
Yes
No
|
| 30.
If yes to #29, please list the preceptor's name, clinic, address,
phone |
|
31.
Where do you intend to practice after your degree program graduation?
|
|
| 32.
Will it be in primary care? |
|
| 33.
Do you plan to remain in SC to practice? |
|
*34.
I agree to respond to requests by SC AHEC for future information
about post-graduation employment (type of practice, setting,
geographic location). I also understand that this information
may be shared with others.
|
Yes
No |
*35.
When you were a child and/or teenager, did you live in a small
town or rural community with a population size less than 5,000
persons that was located at least 30 miles from a town with
more that 25,000 persons?
|
Yes
No |
*36.
Do you currently reside in a small town or rural community with fewer that
5,000 persons that is located at least 30 miles from a town with more than
25,000 persons?
|
Yes
No |
You
have completed this survey. After submitting it You will need
to complete the PreTest in order to finish the application process.
Thank you.
|
|
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