Post-Rotation Survey

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* 1. Please provide your full name:

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* 2. I am a ...

Medical Student

Physician Assistant Student

APRN student

Behavioral Health Student

Medical Assistant Student

Other (please specify):

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* 3. Please provide the name of your school/college/university:

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* 4. During what semester/term did you complete your rotation?

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* 5. What was the start date and end date of your rotation?

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

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* 6. How many rotation hours did you complete with Fairfield Community Health Center?

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* 7. Who did you precept with?

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* 8. I affirm that I have completed the OPCWI post-rotation survey.

I have completed the survey.

I have not completed the survey.

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* 9. Please upload a screen shot of your post-survey confirmation email:

Do not attach your individual answers to post-survey questions. Your survey answers are private and will not be shared with Fairfield Community Health Center

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