HUPC Rural Primary Care Rotation Survey

For questions, please contact Heidi Damron or Jessica Bursk.

HUPC Rural Primary Care Rotation Survey

Please rank your preference of block and location for the required M4 Rural Primary Care rotation. *Note: Every effort is made to place students in their preferred block and location; however, first choices cannot be guaranteed.

STUDENT INFORMATION

Name(Required)

First Last

Email(Required)

Phone(Required)

RESIDENCY INFORMATION

To which specialty are you planning to apply for residency?(Required)

BLOCK PREFERENCE

First Choice(Required)

Second Choice(Required)

Third Choice(Required)

LOCATION PREFERENCE

First Choice(Required)

Second Choice(Required)

Third Choice(Required)

Fourth Choice(Required)

Fifth Choice(Required)

Sixth Choice(Required)

HOUSING INFORMATION

Please indicate if you will provide your own housing or if student housing is needed.(Required)

COMMENTS / ADDITIONAL INFORMATION

Please provide comments or additional information regarding your rotation selection. (optional)