ADFM Administrator Demographics Info Request & Peer Partner Application

1. Demographics

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* 1. Name:

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* 2. Current Job Title:

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* 3. Department/Institution Name:

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* 4. E-Mail Address:

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* 5. How long have you been in your role?

Under 3 years

3 to 5 years

5 to 10 years

More than 10 years

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* 6. How many clinical Faculty are in your department?

# Direct

# Affiliated

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* 7. Describe your department setting.

Allopathic Medical School (MD)

Osteopathic Medical School (DO)

Regional Medical Center (e.g., stand-alone programs)

Other (please specify)

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* 8. Approximately how many research intensive faculty (PhD, MD, or equivalent; more than 50% FTE in research) are in your department?

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* 9. Please list the fellowship programs your department runs:

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* 10. How many family medicine RESIDENCY PROGRAMS are in your department AT your health center(s)? (NOT residents, but programs) Numbers only.

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* 11. How many affiliated family medicine RESIDENCY PROGRAMS are there that are OUTSIDE of your health center (e.g. community-based university administered or formal affiliation with the university)? (NOT residents, but programs) Numbers only.

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* 12. How many ambulatory clinics exist in your department?

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* 13. Which of the following services does your department have?

Women's Health Clinic

Sports Medicine Clinic

Nutrition/Registered Dietitian Services

Behavioral Health Services

Pharmacy Services

Public Health Division

PA Program

Geriatrics Service

Palliative Care Team

Other (please specify)

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* 14. Do you partner with any FQHCs?

Yes

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* 15. Are you a peer partner who is

Newer to your role (less than 3 years)

More experienced in your role (3-5 years)

Not interested in the peer partner program