Name

Email

Home address

Street

City State Zip

Race

American Indian or Alaska Native

Underrepresented Asian Subgroup (Any Asian other than Chinese, Filipino, Japanese, Korean, Asian Indian or Thai)

Asian (Not underrepresented)

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White: disadvantaged

White: Not disadvantaged

Sex

Female

Male

Age

Under 20

20-29

30-39

40-49

50-59

60 or older

Discipline

Are you a graduate or program completer who entered into a residency or practice in underserved areas/communities?

No

Yes - entered into a residency

Yes - entered into a practice