YES, I understand that my responses may be shared among the three participating institutions.
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Your primary institutional/professional email address* must provide value
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Your gender* must provide value
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Your race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than one race Prefer not to answer Don't know
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Your ethnicity Hispanic or Latino/a Not Hispanic or Latino/a Prefer not to answer Don't know
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State in which your primary workplace is located* must provide value
ME NH VT Other state
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Primary workplace zip code* must provide value
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How did you hear about the Northern New England Clinical Translational Research Network (NNE-CTR)?* must provide value
From a colleague From an NNE-CTR staff member From a news media outlet Other
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Other, please specify. * must provide value
What is your highest academic degree? * must provide value
PhD / ScD MD or DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH DVM JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
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What year did you graduate with your highest degree?* must provide value
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Do you have an additional post-graduate degree?* must provide value
Yes No
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What is your additional post-graduate degree? PhD/ScD MD/DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH DVM JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
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What professional license(s) do you currently hold? Please check all that apply. * must provide value
DO
LCPC
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MD
NP
PA
PT
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With what institution(s) are you affiliated? Please check all that apply. * must provide value
University of Vermont College of Medicine
Other University of Vermont College
University of Vermont Medical Center
University of Vermont Health Network
Maine Medical Center / MaineHealth
University of Maine - Orono
University of Southern Maine
Other
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Other, please specify.
With what institution are you Required. Please select below.
You have not selected a primary institution. Please make a selection above.
Which Maine Medical Center department or center are you Anesthesiology Cardiac Surgery Cardiology Center for Molecular Medicine Center for Psychiatric Research Clinical and Translational Science CPI/Enterprise Reporting Critical Care Emergency Medicine Employee Health Endocrinology/Metabolism Family Medicine Gastroenterology Geriatrics Health Sciences Hospital Medicine Infectious Disease Internal Medicine Library Medical Education MMC BioBank Nephrology Neurology Neuroscience Neurosurgery and Spine Nursing Obstetrics Gynecology and Reproductive Oncology Gynecologic Oncology Medical Oncology Pediatric Oncology Radiation Oncology Surgical Orthopedics Outcomes Research and Evaluation Palliative Care Pathology and Laboratory Medicine Pediatrics Pharmacology Pharmacy Physical Therapy Psychiatry Psychology Pulmonary Care Radiology Rehabilitation Medicine Simulation Center Sociology Spiritual Care Sports Medicine Surgery Urology Vascular Surgery Vector-Borne Disease Virology Treatment Center Other
Other, please specify.
Which USM school, college or department are you Muskie School of Public Service School of Nursing School of Social Work School of Business School of Education and Human Development University of Maine Law School Department of Biological Sciences Department of Chemistry Department of Computer Science Department of Engineering Department of Environmental Science and Policy Department of Exercise, Health, and Sport Sciences Department of Linguistics Department of Mathematics and Statistics Department of Physics Department of Psychology Department of Recreation and Leisure Studies Department of Technology Other
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Which UVM Medical Center/UVM College of Medicine department are you Anesthesiology Biochemistry Family Medicine Medicine Microbiology and Molecular Genetics Molecular Physiology and Biophysics Neurological Sciences Obstetrics, Gynecology and Reproductive Sciences Orthopedics and Rehabilitation Pathology and Laboratory Medicine Pediatrics Pharmacology Psychiatry Radiology Surgery Area Health Education Centers (AHEC) Cancer Center Center on Aging Clinical Research Center Office of Clinical Trials Research Health Behavior Research Center Office of Health Promotion Research McClure Musculoskeletal Research Center Microscopy Imaging Center MRI Center for Biomedical Imaging Neuroscience Center (COBRE) Vaccine Testing Center Vermont Center for Children, Youth and Families Vermont Center for Immunology and Infectious Diseases (COBRE) Vermont Center on Behavior and Health (COBRE) Vermont Lung Center (COBRE) Cardiovascular Research Institute of Vermont Laboratory for Clinical Biochemistry Research Program in Integrative Health Program in Public Health The Vermont Breast Cancer Surveillance System Vermont Child Health Improvement Program (VCHIP) Vermont Leadership Education in Neurodevelopmental Disabilities (VT LEND) Vermont Oxford Network
Please list any additional UVM Medical Center or UVM College of Medicine departmental affiliations, if applicable:
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Which UVM College are you Agriculture and Life Sciences Arts and Sciences Business (Grossman) Education and Social Services Engineering and Mathematical Sciences Environment and Natural Resources (Rubenstein) Nursing and Health Sciences Honors Graduate Continuing and Distance Education Extension Other
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With which ______ department or program are you Please use a comma to separate listed items.
With which UVM Health Network organization are you primarily affiliated? Alice Hyde Medical Center Central Vermont Medical Center Champlain Valley Physicians Hospital Elizabethtown Community Hospital Porter Medical Center Pediatric Primary Care Primary Care and Family Medicine Specialty Care Practice Express Care Other
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Which * must provide value
Not Applicable / Not in clinical practice Anesthesiology and Perioperative Medicine Allergy and immunology Anesthesiology Cardiology Cardiovascular surgery Clinical laboratory sciences Dermatology Dietetics Emergency medicine Endocrinology Family medicine Forensic medicine Gastroenterology General surgery Genomics/Genetics Geriatrics Gynecology Hepatology Hospital medicine Infectious disease Intensive care medicine Internal Medicine Medical research Nephrology Neurology Neurosurgery Obstetrics and gynecology Oncology Ophthalmology Oral and maxillofacial surgery Orthopedic surgery Otorhinolaryngology, or ENT Palliative care Pathology Pediatrics Pediatric surgery Physical medicine and rehabilitation Plastic surgery Podiatry Proctology Psychiatry Pulmonology Public Health Radiology Rheumatology Surgical oncology Thoracic surgery Transplant surgery Urgent Care Medicine Urology Vascular surgery Other
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How many years have you been involved in clinical practice? * must provide value
Less than one year One to three years Four to six years Seven to nine years Ten or more years Not Applicable
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Do you currently practice in a rural clinical setting? * must provide value
Yes No
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Are you a: Intern/Practicum student
Fellow
Resident
None of the above
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