Research Questions 2010 Application - Summer Training Program in Addiction Medicine

Research Questions 2010 Application - Summer Training Program in Addiction Medicine

Dear Colleague: We're delighted by your interest in the summer training program in addiction medicine. Below you'll find a questionnaire that asks some personal questions about your attitudes and behaviors. The data you provide are confidential, will not be linked to you by name, will only be used when combined with the data from all the other applicants, will not be used for selecting applicants, and will not be shared with anyone. We are collecting these data because we want to know how well our training programs work. If you have questions about any of this, you may contact Dr. Erica Frank <efrank@emory.edu>.

1. Today's date __/__/2010

(MM/DD/YYYY)

2. Your year of birth: 19__

(YYYY)

3. Gender:

4. Current educational level:

Undergraduate

Summer after MS1

Summer after MS2

Summer after MS3

Summer after MS4

Other (please specify)

5. Mother's initials at her birth:

(we will use this to anonymously track you over time)

6. Choose the one specialty you are now most interested in pursuing:

Addiction Medicine

Emergency Medicine

Family Medicine

General Internal Med.

Med. - Subspecialist

Ob/Gyn

Pediatrics - General

Ped.- Subspecialist

Preventive Med./Public Health

Psychiatry

Surgery

Urology

Anesthesia /pathology / radiology

Undecided

Other (please specify)

7. During the past month, on about how many days did you drink any alcoholic beverages?

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