First Name *

Last Name *

Institution *

Email *

Phone *

What is your institution type? *

Private University

Public University

Veterans Administration

Is your primary hospital owned by the University? *

Enter required value Yes No

Is your healthcare system fully academic, or a mix of private practice and academic? *

Enter required value Fully (100%) Academic Mixed

Does the Department include Child Neurology? *

Enter required value Yes No

Is the Neurology clerkship mandatory? *

Enter required value Yes No

If not, what percentage of the medical school class takes the Neurology clerkship?

Less than 1/3 1/3 – 2/3 Greater than 2/3

How many different clerkship sites do you supervise? (Numerical answer only) *

Is your clerkship part of a larger clerkship rotation? *

Enter required value Yes No

Length of your rotation: *

Enter required value Fewer than 4 weeks 4 weeks More than 4 weeks

Is your clerkship required to be completed prior to the senior year? *

Enter required value Yes No

Are you using community mentors in the Neurology clerkship? *

Enter required value Yes No

What is your medical school class size? *

Enter required value Small (50 or fewer) Medium (51 - 150) Large (150+)

What experiences have you had? *

Enter required value Started a new clerkship Redesigned a clerkship Neither

Were you mentored when you took on your current role? *

Enter required value Yes No

On what issues/areas do you feel you can provide mentoring? *

(Please list in order of importance.)

Please name any individuals would you prefer NOT to have as a mentee.

Additional Comments (optional)