Form 4 Graduation Survey

Residency Program Feedback

1. What are the strengths of your residency program?
5
6  

2. How do you think your residency program could be improved?
5
6  

Residency Program Career Planning

3. Please describe any career planning/mentorship provided by your residency program.
5
6  

4. Based on your experience, indicate your level of satisfaction with the career
planning/mentorship you received during your residency.
Very Dissatisfied

Dissatisfied

Neutral

Satisfied

Very Satisfied

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

Preparedness for Practice

5. Please indicate whether you agree with the following statements.
Strongly 
I feel well prepared to practice independently in an inpatient hospital 

Strongly 

Disagree

Neutral

Agree

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

Disagree

Agree

setting.
I feel well prepared to practice independently in an outpatient primary 
care setting.

Career Plans

6. What are your plans following graduation?
5
6  

7. After all residency and fellowship training, do you plan to practice in Primary Care?

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

j Undecided
k
l
m
n

8. After all residency and fellowship training, do you plan to practice in an underserved
area?

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

j Undecided
k
l
m
n

9. If you plan to practice in an underserved area, please indicate the likely location.
j Rural community
k
l
m
n

j Inner­city community
k
l
m
n

Other (please specify) 

Job Information

Please complete this page if you have accepted a job following your residency training. 

10. If you have a job, please provide the following information:
Position Title
Organization Name
Address (primary clinical 
site)
City
State
Zip Code
Country
Primary Responsibilities

11. Is your position an academic position?

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

12. Will you be participating in a loan repayment program in this position?

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

j Unsure
k
l
m
n

13. If you will receive loan repayment in your next position, please indicate the type of loan
repayment program. Choose all that apply.
c Department of Education’s Public Service Loan Forgiveness (PSLF)
d
e
f
g
c National Health Service Corps Scholarship
d
e
f
g

c National Health Service Corps Loan Repayment
d
e
f
g
c Indian Health Service Corps
d
e
f
g

c Armed Services (Navy, Army, Air Force)
d
e
f
g
c Uniformed Service (CDC, HHS)
d
e
f
g

c State loan forgiveness program
d
e
f
g

c Hospital program (e.g. sign­on bonus)
d
e
f
g
Other (please specify) 

Fellowship Training

14. Are you planning on fellowship training after your residency program?

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

j Unsure
k
l
m
n

15. If you have a fellowship position, please provide the following information:
Specialty
Program Name
City
State
Country