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First Name:
Last Name:
Title:
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State/Province (N/A if not applicable):
Country:
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Please Select your Member Type: Faculty: Allopathic, Osteopathic, Nurse Practitioners and Physicians Assistants - $320
Administrators: Clerkship and medical education administrator staff - $110
Trainees: students, residents, fellows - $50
Emeritus: retired faculty or administrators - $50
 

Which of the following best describes your CURRENT educator position? (select one) Clerkship Director at the central campus
Clerkship Director at a geographic location other than the central campus (e.g. Site Director)
Assistant or Associate clerkship director at a central campus
Assistant or Associate Clerkship Director at a regional campus
Director or Assistant Director of fourth year programs for Pediatrics
Pediatric Clerkship Ambulatory Block Director
Pediatric Clerkship Inpatient Block Director
Associated with a Deans office or office of medical education
Teaching Faculty
Clerkship Administrator
Resident/Fellow/Medical Student
Other:
 

Indicate your professional degrees from the list below (select all that apply) MD
FRCPC
DO
PhD
MPH
M.Ed
EdD
PhD in Education
MS
Bachelors
Other Masters
Other educational degrees
High School
 

COMSEP Collaboratives focus on important topics in undergraduate medical education. Exciting projects and efforts emerge from the ideas and energy shared by members in each collaborative. Please indicate which collaborative(s) you would like to join to make a difference in undergraduate medical education!
 
Indicate collaboratives (select all that apply) Administrators Collaborative
Assessment & Evaluation Collaborative
Career Advising Collaborative
Core Clerkship Collaborative
Professional and Faculty Development Collaborative
Pre-clerkship & Clinical Skills Collaborative
Post-clerkship (M4 & Residency prep) Collaborative
Research & Scholarship Collaborative
Student Wellness Collaborative
Technology Collaborative
 

Are you certified in a subspecialty area? If yes, choose which subspecialty: Academic Generalist
Adolescent Medicine
Allergy/Immunology
Cardiology
Child Abuse
Critical Care
Dermatology
Developmental & Behavioral Pediatrics
Emergency Medicine
Gastroenterology
Genetics
Hematology Oncology
Hospital Medicine
Infectious Disease
Internal Medicine-Pediatrics
Neonatology
Nephrology
Palliative Care
Pulmonary
Rheumatology
Sports Medicine
Other:
 

What is your gender? Female
Male
Do not want to respond
 

What is your age? < 30 years
31-35 years
36-40 years
41-45 years
46-50 years
51-55 years
56-60 years
61-65 years
> 65 years
 

Race/Ethnicity (check all that apply)
If you choose "other", please describe your race/ethnicity
Caucasian, Non-Hispanic
Hispanic/Latino
African-American/Black
Asian
Unknown
Prefer not to answer
Other:
 
 

With which medical school are you affiliated?
Other:
 

What is your current academic rank? Instructor
Assistant Professor
Associate Professor
Professor
Administrator
Emeritus

Length of time (in years) in any role as a medical educator.

If you currently are a clerkship director or associate clerkship director, length of time (in years) in that role:

Which of the following best describes your clerkship structure: Departmentally based single specialty
Interdepartmental clerkship
Longitudinal integrated clerkship
Other:

What is the size of each class in your medical school?

How many weeks long is the Pediatric Clerkship at your institution?
 

Method of payment

Credit card online
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