Rotation/clerkship form
The Northcentral Pennsylvania AHEC (Area Health Education Center) is seeking to help meet the health care needs of our communities.  Trends in types of environments a person lived in, had rotations in and practice in may assist in deciding how to recruit or train health care professionals.  All survey responses are confidential. Data will only be used within the AHEC program and never for commercial purposes. 
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First name *
Last Name *
Birthdate-  month and year *
Email *
Back ground information
High School zip code *
Hometown type *
Veteran Status *
Gender *
Ethnicity
Clear selection
Race
Clear selection
Name of College or University *
Name of  Degree Program *
Expected Graduation month and year *
Type of program *
Name of rotation site *
Name of preceptor(s)
Start date
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YYYY
End Date
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DD
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YYYY
Do you intend to practice in Pennsylvania? *
The type of area intend to practice in is *
Required
Do you intend to practice primary care?
Clear selection
Do you intend on praciticing in a Medically Underserved Area?
Clear selection
Did completing this rotation help you decide if you wanted to practice in a rural or urban underserved area? *
In terms of Health Profession Shortage Areas/ Dental  Health Profession Shortage Areas sites
Clear selection
In terms of an employment site and its community, what are your top 5 priorities? *
Required
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