UCSD CIM Membership Survey--Short

1. Welcome to the UCSD Center for Integrative Medicine

Thank you for your interest in applying to become affiliated with the UCSD Center for Integrative Medicine.We look forward to your help and support in growing this exciting mission to bring whole-person health and healing throughout UC San Diego and beyond.

But first we need to know who you are, what you do, and what role you would like to play in this important and groundbreaking effort. Take a few minutes to carefully consider the questions below and respond accordingly. We will follow up on your responses as the circumstances warrant and we look forward to connecting with you more!

UCSD CIM Executive Committee:
Rusty Kallenberg, MD; Lauray MacElhern, MBA; Ellen Beck, MD; Aaron Cook, LAc; Steven Hickman, PsyD; Michael Kurisu, DO; Gordon Saxe, MD, PhD; Paul Mills, PhD

Question Title

* Please provide us with a little information about you and how to contact you. (Note: if you are a UCSD employee or student, please use your UCSD email address.)

Name: *

Company:

Title:

Address:

City/Town:

State:

ZIP:

Email Address: *

Phone Number: *

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* How would you best categorize your current involvement in Integrative Medicine? (Check all that apply.)

Consumer

Practitioner/clinician

Interested observer

Student

Faculty/professor

Researcher

Other (please specify)

Question Title

* Please provide a very short summary (1 paragraph maximum) describing your current interest and experience in the field of Integrative Medicine.

Question Title

* If you have a Web site or page that relates to the CIM, please insert the URL below:

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* Which of these categories best describe your interest in being a future "member" of the Center for Integrative Medicine (CIM)? Note that this may be different than what you are currently doing in Integrative Medicine. As a CIM Member, I would like to:

Provide clinical services

Conduct research

Promote the CIM (i.e. marketing, outreach, administrative support, etc.)

Incorporate IM in education/study (i.e. teaching, student, trainee, etc.)

Stay informed about the CIM - keep me on your list

Participate actively in building the UCSD CIM Community

Be a consumer of CIM services

Help with/contribute to fundraising

Other (please specify)

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* We hope to capitalize on the interests and expertise of our community by matching each person to particular efforts, projects or committees of the CIM. Please take a moment to either check one of the existing committees below as one in which you have an interest, or note in the comment box what sort of things you might be willing to initiate or support to help establish and grow the CIM.

Clinical committee

Research committee

Education committee

Community Partnerships committee

I am not interested in joining a committee

Other (please specify)

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* How active do you anticipate your involvement with the CIM will be?

Very active - daily or weekly engagement

Somewhat active

Not active, but I am an interested observer