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Today's Date:
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Your First Name:
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Your Last Name:
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Your Email Address:
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Your Phone:
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What year did you graduate?
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Please provide contact information for two peers that would be willing to evaluate you (name, e-mail, phone):
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Please provide contact information for your current employer (name, e-mail, phone):
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1. Have you taken your Boards?
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Yes
No
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1A. Please indicate whether you are board certified.
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Board Certified
Not Board Certified
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1B. Which Specialty Board?
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1C. Other Certifications.
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2. Have you started a fellowship after graduating from the residency?
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Yes
No
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2A. If yes, Please provide sub-specialty and sponsoring institution.
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3. Did you start another residency after graduating from your first Arizona residency?
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Yes
No
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3A. If yes, Please provide specialty and sponsoring institution.
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4. What is your PRIMARY career status?
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Office Based
Hospital Based
Office and Hospital Based
Other Medical Based
Non-Medical Based
Education
Searching for Employment/Other
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4A. Office Based
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a. Private Practice - solo
b. Private Practice - group
c. An employee in a group practice
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4B. Hospital Based
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a. Hospitalist
b. Academic Medicine
c. Other specialty hospital employee (surgeon, anesthesiologist, etc)
d. Other
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4C. Office and Hospital Based
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a. Private practice - solo
b. Private practice - group
c. An employee in a group practice
d. Hospitalist
e. Academic Medicine
f. Other specialty hospital employee (surgeon, anesthesiologist, etc.)
g. Other
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4D. Other Medical Based
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a. Academic Medicine
b. Military/VA
c. Indian Health Service or tribal health sites
d. Volunteer
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4E. Non-Medical Based
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a. Employee in another medical career non-medical
b. Self employed in another medical career non-medical
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4F. Education
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a. Fellowship
b. Another residency
c. Other schooling non-medical (MBA, etc.)
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4G. Searching for Employment/Other
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Searching for Employment/Other
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4G-a. If a group practice is selected: What is the number of physicians in the group?
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2
3-5
6-10
11-24
25+
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4G-b. If a non-medical choice is selected: Please describe reason you are not currently practicing medicine?
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4G-c-1. If a medical choice is selected: In what specialty do you currently practice?
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4G-c-2. Where are you practicing? (State i.e. AZ, CA, etc.)
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4G-c-3. Which best describes the community in which you practice?
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A community of less than 2,500 people
A small town of 2,500 to 10,000
A medium-sized town of 10,000 to 25,000
A large town of 25,000 to 50,000
A small city of 50,000 to 100,000
A large city of 100,000 to 500,000
A suburb of a large city
A city > 500,000
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4G-c-4. Do you use a computer in your practice?
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yes
no
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4G-c-5. If you do use a computer in your practice, for which of the following functions?
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Appointments
Billing
E-mail
Internet Access
Medline Searching
Storing and retrieving patients' medical data
Other
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5. Did you apply for hospital privileges?
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yes
no
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5A. If yes, did you get hospital privileges?
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yes
no
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5A-a. When you applied for hospital privileges and did not receive them, it had a significant impact on my planned practice. (1=Strongly agree, 2=Agree, 3=Neutral, 4=Disagree, 5=Strongly disagree)
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1
2
3
4
5
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6A. Please select how satisfied/dissatisfied you are with the following items: Chosen specialty. (1=Very Satisfied, 2=Somewhat Satisfied, 3=Neutral, 4=Somewhat Dissatisfied, 5=Very Dissatisfied)
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1
2
3
4
5
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6B. Please select how satisfied/dissatisfied you are with the following items: Professional life. (1=Very Satisfied, 2=Somewhat Satisfied, 3=Neutral, 4=Somewhat Dissatisfied, 5=Very Dissatisfied)
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1
2
3
4
5
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6C. Please select how satisfied/dissatisfied you are with the following items: Practice arrangement. (1=Very Satisfied, 2=Somewhat Satisfied, 3=Neutral, 4=Somewhat Dissatisfied, 5=Very Dissatisfied)
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1
2
3
4
5
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6D. Please select how satisfied/dissatisfied you are with the following items: Income. (1=Very Satisfied, 2=Somewhat Satisfied, 3=Neutral, 4=Somewhat Dissatisfied, 5=Very Dissatisfied)
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1
2
3
4
5
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6E. Please select how satisfied/dissatisfied you are with the following items: Personal life. (1=Very Satisfied, 2=Somewhat Satisfied, 3=Neutral, 4=Somewhat Dissatisfied, 5=Very Dissatisfied)
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1
2
3
4
5
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6F. Please select how satisfied/dissatisfied you are with the following items: Community life. (1=Very Satisfied, 2=Somewhat Satisfied, 3=Neutral, 4=Somewhat Dissatisfied, 5=Very Dissatisfied)
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1
2
3
4
5
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7. How easy or difficult has it been for you to maintain a balance between your personal life and your professional life? (1=Extremely Easy, 2=Fairly Easy, 3=Neither Easy nor Difficult, 4=Fairly Difficult, 5=Extremely Difficult)
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1
2
3
4
5
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8. If you had it to do all over, would you choose to complete the Arizona residency which you chose? (1=Definitely would, 2=Probably would, 3=Uncertain, 4=Probably not, 5=Definitely not)
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1
2
3
4
5
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9. Would you still choose the same specialty again? (1=Definitely would, 2=Probably would, 3=Uncertain, 4=Probably not, 5=Definitely not)
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1
2
3
4
5
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10. Would you still choose a career in medicine? (1=Definitely would, 2=Probably would, 3=Uncertain, 4=Probably not, 5=Definitely not)
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1
2
3
4
5
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11A. Please evaluate yourself in regard to: Patient Care; I practice in a manner that meets my expectations for excellence. (1=always, 2=usually, 3=sometimes, 4=occasionally, 5=never, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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11B-a. Please evaluate yourself in regard to: Medical Knowledge; My fund of knowledge is appropriate for my level of experience. (1=always, 2=usually, 3=sometimes, 4=occasionally, 5=never, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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11B-b. Please evaluate yourself in regard to: Medical Knowledge; I use evidence based medicine in caring for patients. (1=always, 2=usually, 3=sometimes, 4=occasionally, 5=never, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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11C-a. Please evaluate yourself in regard to: Interpersonal/Communication Skills; I effectively build rapport with patients, peers, and staff. (1=always, 2=usually, 3=sometimes, 4=occasionally, 5=never, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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11C-b. Please evaluate yourself in regard to: Interpersonal/Communication Skills; I communicate factual material effectively. (1=always, 2=usually, 3=sometimes, 4=occasionally, 5=never, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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11D. Please evaluate yourself in regard to: Professionalism; I demonstrate professionalism (altruistic, truthful, ethical, respectful, responsible, self-aware). (1=always, 2=usually, 3=sometimes, 4=occasionally, 5=never, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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11E. Please evaluate yourself in regard to: System-Based Practice; I use the medical care system in advocating for patients. (1=always, 2=usually, 3=sometimes, 4=occasionally, 5=never, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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11F. Please evaluate yourself in regard to: Practice Based Learning and Improvement; I work to improve patient care outcomes based on my practice experience. (1=always, 2=usually, 3=sometimes, 4=occasionally, 5=never, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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12. Do you believe your residency prepared you to perform your duties competently as a physician in your specialty? (1=very well, 2=well, 3=enough, 4=a little, 5=no, UTE=unable to evaluate)
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1
2
3
4
5
UTE
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13. We would welcome any specific suggestions for improving the residency.
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