Form 2 Alumni Survey

Certification & Licensing

1. Are you currently board certified?

j Yes
k
l
m
n
j No
k
l
m
n

2. If yes, what board certifications do you maintain? Please check all that apply and add
any specialty certifications as appropriate.
c Family Medicine ­ ABFM
d
e
f
g
c Family Medicine ­ AOA
d
e
f
g

c Internal Medicine ­ ABIM
d
e
f
g
c Internal Medicine ­ AOA
d
e
f
g
c Pediatrics ­ ABP
d
e
f
g

c OB/Gyn ­ AOA
d
e
f
g

c Pediatrics ­ AOA
d
e
f
g
c OB/Gyn ­ ABOG
d
e
f
g

c Psychiatry ­ ABPN
d
e
f
g
c Psychiatry ­ AOA
d
e
f
g

c General Dentistry ­ ABGP
d
e
f
g

c Pediatric Dentistry ­ ABPD
d
e
f
g

Other (please specify) 

3. Do you currently hold an active medical or dental license?

j Yes
k
l
m
n
j No
k
l
m
n

4. If yes, in what state(s) do you hold an active license?

Currently in Training

5. Are you currently in a training position, such as a residency or fellowship?

j Yes
k
l
m
n
j No
k
l
m
n

Current Training Position

6. If yes, please provide the following information for the training position:
Specialty/Name of
Program:
Organization:
City/Town:
State:

6

Country:

Additional Training

7. Have you completed any additional training, such as a residency or fellowship, since
your primary care residency program?

j Yes
k
l
m
n
j No
k
l
m
n

Additional Training Positions

8. Please provide the following information for the most recent training position:
Specialty/Name of
Program:
Organization:
City/Town:
State:

6

Country:

9. Please provide the following information for the next most recent training position (if
applicable):
Specialty/Name of
Program:
Organization:
City/Town:
State:

6

Country:

10. Please provide the following information for the next most recent training position (if
applicable):
Specialty/Name of
Program:
Organization:
City/Town:
State:

6

Country:

Post­Graduate Employment

11. Are you currently employed in a non­training position?

j Yes
k
l
m
n
j No
k
l
m
n

12. If yes, how would you classify your current primary employer?
j Academia
k
l
m
n

j Cit/County Government
k
l
m
n

j Community­based organization/nonprofit
k
l
m
n
j Federal Government
k
l
m
n
j Hospital
k
l
m
n

j Private Industry
k
l
m
n

j State Government
k
l
m
n
j Unknown
k
l
m
n

Other (please specify) 

13. Are you currently practicing clinical medicine or dentistry?

j Yes
k
l
m
n
j No
k
l
m
n

Principal Clinical Practice Site

14. Please enter the following information for you PRINCIPAL practice site ­ this is the
physical location where you spend most of your patient care time.
Name:
Address:
Address 2:
City/Town:
State:

6

ZIP:
Country:

15. What specialty do you primarily practice in this setting? Choose one.
c General Family Medicine
d
e
f
g

c General Internal Medicine
d
e
f
g
c General Pediatrics
d
e
f
g
c OB/Gyn
d
e
f
g

c Psychiatry
d
e
f
g
c Geriatrics
d
e
f
g
c Dentistry
d
e
f
g

Other (please specify) 

16. What percent of a full­time equivalent (FTE) are you working at this site (Full­time
=100%)?

17. Which of the following best describes the principal method by which you are paid in
this practice setting? Check one:
j Salary
k
l
m
n

j Receipts
k
l
m
n

j Base salary plus production incentive
k
l
m
n
Other (please specify) 

18. Which of the following best describes your principal practice setting (check all that
apply)?
c Locums
d
e
f
g

c Fee for service practice
d
e
f
g
c HMO
d
e
f
g

c Teaching program
d
e
f
g
c Military
d
e
f
g

c Hospital
d
e
f
g

c Emergency Medicine
d
e
f
g
c Urgent Care
d
e
f
g

Other (please specify) 

19. Which of the following best describes the practice organization of your principal
practice (check only one):
j Solo
k
l
m
n

j Partnership (2­physician practice)
k
l
m
n

j Single specialty group (3 or more physicians)
k
l
m
n
j Multi­specialty partnership or group
k
l
m
n
j Hospital owned
k
l
m
n

j Academic program
k
l
m
n
Other (please specify) 

20. Does this practice site fall into any of the following federally designated
areas/practices? Check all that apply.
c HPSA: Federally designated health professional shortage area
d
e
f
g
c MUA: Federally designated medically underserved area
d
e
f
g
c MHC: Federally designated migrant health center
d
e
f
g

c NHSC: National Health Service Corps
d
e
f
g

c FQHC: Federally Qualified Health Center
d
e
f
g

c State or Local Health Department
d
e
f
g

c IHS: Indian Health Service site or tribal clinic
d
e
f
g

c State qualified health center/clinic
d
e
f
g

c CHC: Federally designated community health center
d
e
f
g
c RHC: Federally designated rural health clinic
d
e
f
g

Other underserved poopulation (please specify) 

21. Please describe the ethnicity of your patient population at this site (approx):
% Hispanic/Latino
% Not Hispanic/Latino

22. Please describe the race of your patient population at this site (approx):
% American Indian or 
Alaska Native
% Asian
% Black or African­American
% Native Hawaiian or other 
Pacific Islander
% White

23. What is the approximate percent of patients who are on Medicaid in this practice?
j 0­9%
k
l
m
n

j 10­30%
k
l
m
n
j 31­50%
k
l
m
n
j 51­70%
k
l
m
n
j 71­90%
k
l
m
n

j 91­100%
k
l
m
n

j Don't know
k
l
m
n

24. What is the approximate percent of patients who are uninsured in this practice?
j 0­9%
k
l
m
n

j 10­30%
k
l
m
n
j 31­50%
k
l
m
n
j 51­70%
k
l
m
n
j 71­90%
k
l
m
n

j 91­100%
k
l
m
n

j Don't know
k
l
m
n

25. How many patients do you typically see in this practice setting during a whole day of
practice? (Please use an integer)

26. Are you providing patient care at any other sites?

j Yes
k
l
m
n
j No
k
l
m
n

Additional Clinical Site #1

27. Please enter the following information for the clinical site you spend the next most time
in:
Name:
Address:
Address 2:
City/Town:
State:

6

ZIP:
Country:

28. What specialty do you primarily practice in this setting? Choose one.
c General Family Medicine
d
e
f
g

c General Internal Medicine
d
e
f
g
c General Pediatrics
d
e
f
g
c OB/Gyn
d
e
f
g

c Psychiatry
d
e
f
g
c Geriatrics
d
e
f
g
c Dentistry
d
e
f
g

Other (please specify) 

29. Which of the following best describes the principal method by which you are paid in
this practice setting? Check one:
j Salary
k
l
m
n

j Receipts
k
l
m
n

j Base salary plus production incentive
k
l
m
n
Other (please specify) 

30. Which of the following best describes this practice setting (check all that apply)?
c Locums
d
e
f
g

c Fee for service practice
d
e
f
g
c HMO
d
e
f
g

c Teaching program
d
e
f
g
c Military
d
e
f
g

c Hospital
d
e
f
g

c Emergency Medicine
d
e
f
g
c Urgent Care
d
e
f
g

Other (please specify) 

31. Which of the following best describes the practice organization of this practice setting
(check only one):
j Solo
k
l
m
n

j Partnership (2­physician practice)
k
l
m
n

j Single specialty group (3 or more physicians)
k
l
m
n
j Multi­specialty partnership or group
k
l
m
n
j Hospital owned
k
l
m
n

j Academic program
k
l
m
n
Other (please specify) 

32. Does this practice site fall into any of the following federally designated
areas/practices? Check all that apply.
c HPSA: Federally designated health professional shortage area
d
e
f
g
c MUA: Federally designated medically underserved area
d
e
f
g
c MHC: Federally designated migrant health center
d
e
f
g

c NHSC: National Health Service Corps
d
e
f
g

c FQHC: Federally Qualified Health Center
d
e
f
g

c State or Local Health Department
d
e
f
g

c IHS: Indian Health Service site or tribal clinic
d
e
f
g

c State qualified health center/clinic
d
e
f
g

c CHC: Federally designated community health center
d
e
f
g
c RHC: Federally designated rural health clinic
d
e
f
g

Other underserved poopulation (please specify) 

33. What percent of a full­time equivalent (FTE) are you working at this site (Full­time
=100%)?

34. How many patients do you typically see in this practice setting during a whole day of
practice? (Please use an integer)

35. Are you providing patient care at any other sites?

j Yes
k
l
m
n
j No
k
l
m
n

Additional Clinical Site #2

36. Please enter the following information for the clinical site you spend the next most time
in:
Name:
Address:
Address 2:
City/Town:
State:

6

ZIP:
Country:

37. What specialty do you primarily practice in this setting? Choose one.
c General Family Medicine
d
e
f
g

c General Internal Medicine
d
e
f
g
c General Pediatrics
d
e
f
g
c OB/Gyn
d
e
f
g

c Psychiatry
d
e
f
g
c Geriatrics
d
e
f
g
c Dentistry
d
e
f
g

Other (please specify) 

38. Which of the following best describes the principal method by which you are paid in
this practice setting? Check one:
j Salary
k
l
m
n

j Receipts
k
l
m
n

j Base salary plus production incentive
k
l
m
n
Other (please specify) 

39. Which of the following best describes this practice setting (check all that apply)?
c Locums
d
e
f
g

c Fee for service practice
d
e
f
g
c HMO
d
e
f
g

c Teaching program
d
e
f
g
c Military
d
e
f
g

c Hospital
d
e
f
g

c Emergency Medicine
d
e
f
g
c Urgent Care
d
e
f
g

Other (please specify) 

40. Which of the following best describes the practice organization of this practice setting
(check only one):
j Solo
k
l
m
n

j Partnership (2­physician practice)
k
l
m
n

j Single specialty group (3 or more physicians)
k
l
m
n
j Multi­specialty partnership or group
k
l
m
n
j Hospital owned
k
l
m
n

j Academic program
k
l
m
n
Other (please specify) 

41. Does this practice site fall into any of the following federally designated
areas/practices? Check all that apply.
c HPSA: Federally designated health professional shortage area
d
e
f
g
c MUA: Federally designated medically underserved area
d
e
f
g
c MHC: Federally designated migrant health center
d
e
f
g

c NHSC: National Health Service Corps
d
e
f
g

c FQHC: Federally Qualified Health Center
d
e
f
g

c State or Local Health Department
d
e
f
g

c IHS: Indian Health Service site or tribal clinic
d
e
f
g

c State qualified health center/clinic
d
e
f
g

c CHC: Federally designated community health center
d
e
f
g
c RHC: Federally designated rural health clinic
d
e
f
g

Other underserved poopulation (please specify) 

42. What percent of a full­time equivalent (FTE) are you working at this site (Full­time
=100%)?

43. How many patients do you typically see in this practice setting during a whole day of
practice? (Please use an integer)

44. Are you providing patient care at any other sites?

j Yes
k
l
m
n
j No
k
l
m
n

Additional Clinical Site #3

45. Please enter the following information for the clinical site you spend the next most time
in:
Name:
Address:
Address 2:
City/Town:
State:

6

ZIP:
Country:

46. What specialty do you primarily practice in this setting? Choose one.
c General Family Medicine
d
e
f
g

c General Internal Medicine
d
e
f
g
c General Pediatrics
d
e
f
g
c OB/Gyn
d
e
f
g

c Psychiatry
d
e
f
g
c Geriatrics
d
e
f
g
c Dentistry
d
e
f
g

Other (please specify) 

47. Which of the following best describes the principal method by which you are paid in
this practice setting? Check one:
j Salary
k
l
m
n

j Receipts
k
l
m
n

j Base salary plus production incentive
k
l
m
n
Other (please specify) 

48. Which of the following best describes this practice setting (check all that apply)?
c Locums
d
e
f
g

c Fee for service practice
d
e
f
g
c HMO
d
e
f
g

c Teaching program
d
e
f
g
c Military
d
e
f
g

c Hospital
d
e
f
g

c Emergency Medicine
d
e
f
g
c Urgent Care
d
e
f
g

Other (please specify) 

49. Which of the following best describes the practice organization of this practice setting
(check only one):
j Solo
k
l
m
n

j Partnership (2­physician practice)
k
l
m
n

j Single specialty group (3 or more physicians)
k
l
m
n
j Multi­specialty partnership or group
k
l
m
n
j Hospital owned
k
l
m
n

j Academic program
k
l
m
n
Other (please specify) 

50. Does this practice site fall into any of the following federally designated
areas/practices? Check all that apply.
c HPSA: Federally designated health professional shortage area
d
e
f
g
c MUA: Federally designated medically underserved area
d
e
f
g
c MHC: Federally designated migrant health center
d
e
f
g

c NHSC: National Health Service Corps
d
e
f
g

c FQHC: Federally Qualified Health Center
d
e
f
g

c State or Local Health Department
d
e
f
g

c IHS: Indian Health Service site or tribal clinic
d
e
f
g

c State qualified health center/clinic
d
e
f
g

c CHC: Federally designated community health center
d
e
f
g
c RHC: Federally designated rural health clinic
d
e
f
g

Other underserved poopulation (please specify) 

51. What percent of a full­time equivalent (FTE) are you working at this site (Full­time
=100%)?

52. How many patients do you typically see in this practice setting during a whole day of
practice? (Please use an integer)

53. Are you providing patient care at any other sites?

j Yes
k
l
m
n
j No
k
l
m
n

Patient Encounters

54. On average, how many face­to­face patient encounters do you have per week in each
of the following settings? (Please use an integer for each)
Office
Hospital
Nursing Home
Home Visit
Emergency Department
Other (Specify setting and 
number)

Non­Patient Care Time

55. Do you have time in your job reserved for non­patient care related activities?

j Yes
k
l
m
n
j No
k
l
m
n

56. If yes, please indicate what percent of FTE you are working in each of the following
areas:
Teaching
Research
Administration
Other (Please specify area 
and FTE)

57. Are you currently involved in community service related to your position as a health
care provider in the community? Examples might include working with a free clinic,
conducting health outreach, or working with a local health related agency.

j Yes
k
l
m
n
j No
k
l
m
n

58. If yes, please describe how you are involved in community service related to your
position as a health care provider in the community.
5
6  

Non­Practicing

59. If you are not practicing clinical medicine or dentistry, what are you currently doing?
5
6  

Previous Employment

60. Have you held any other jobs since graduating from your primary care residency?

j Yes
k
l
m
n
j No
k
l
m
n

61. If yes, please provide the following information for the most recent employment:
Specialty of Practice:
Organization:
City/Town:
State:

6

ZIP:
Country:
Start Date: (Month/Yr)
End Date: (Month/Yr)

62. Please provide the following information for the next most recent employment (if
applicable):
Specialty of Practice:
Organization:
City/Town:
State:

6

ZIP:
Country:
Start Date: (Month/Yr)
End Date: (Month/Yr)

63. Please provide the following information for the next most recent employment (if
applicable):
Specialty of Practice:
Organization:
City/Town:
State:

6

ZIP:
Country:
Start Date: (Month/Yr)
End Date: (Month/Yr)

Residency Feedback

64. Are there areas that should have received MORE emphasis during your residency?
5
6  

65. Are there areas that should have received LESS emphasis during your residency?
5
6  

66. How satisfied are you with your residency training in the following areas?
1 (Unsatisfied)

2

3

4

5 (Highly Satisfied)

Medical Knowledge

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Procedural Skills

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Practice Management

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Communication Skills

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Medical Ethics

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Overall

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Practice Satisfaction

67. Please indicate your level of satisfaction with you principal practice in the following
areas:
1 (Unsatisfied)

2

3

4

5 (Highly Satisfied)

Location

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Colleagues

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Employer

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Hours

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Income

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Overall

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

68. In your practice, what is the greatest source of satisfaction?
5
6  

69. In your practice, what is the greatest source of dissatisfaction?
5
6  

70. Please answer the following:

How satisfied are you with your choice of 

5 (Highly 

1 (Unsatisfied)

2

3

4

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Satisfied)

medicine/dentistry as a profession?
How satisfied are you with your choice of specialty?

Contact Information

71. Please provide any updates in your contact information for your residency program:
Name:
Address:
Address 2:
City/Town:
State:

6

ZIP:
Country:
Email Address:
Phone Number:

Comments

Thank you for completing this survey. Please provide any additional comments either in regard to the survey or to your 
residency program in the space below. 

72. Comments
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