First Name *

Last Name *

Institution *

Email *

Phone *

What is your institution type? *

Private University

Public University

Veterans Administration

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

Enter required value Fully (100%) Academic Mixed

Is your primary hospital owned by the University? *

Enter required value Yes No

Were you previously an Associate Clerkship Director? *

Enter required value Yes No I'm currently an ACD

How many different clerkship sites do your supervise? *

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 More than 2/3

Length of your rotation *

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

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+)

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

Enter required value Yes No

What issues/areas do you most want to be matched for? (Please list in order of importance) *

What are three objectives you hope to get out of the coaching program? *

Please name up to 2 CDs you would welcome as a Coach.

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

Additional Comments (optional)