Current Information on Name * E-mail Address * Home Address * Home Phone # Cell/Mobile# Work Name & Address Work Phone# Work Fax# Update us on your activities 1. Current Position (specify resident, fellow, faculty, private practice) Institutional Affiliation/Field of practice 2. Please check those categories below which apply to your current position: Clinical Research Academic Non-academic 3. Have you done research since your short-term fellowship? Yes No 4. Are you currently doing research? Clinical Basic No 5. Do you plan to do research in the future? Yes No 6. In what ways was your student research a valuable experience? (check all that apply) Explore what research is about Enhance research skills Summer seminars Opportunity to present and publish Support of faculty mentor Improve credentials for residency 7. Were the results of your summer research published? Yes (please send CV to firstname.lastname@example.org) No 8. Additional Comments Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.