What year were you born?
Please list your minor children's ages.
Why did you go into medicine?
What clinical area best fits your previous clinical focus?
What is your current clinical board status?
What year will you certify / re-certify?
If your certification has expired, select the date when you were to have re-certified.
Please describe the organization where you work.
Select the range of effort that best describes the average percentage of time you spent in management / leadership before your current job.
Describe anything not included above that contributed to your decision to take on your first management role.
Describe anything not included above that contributed to your decision to move to full-time management.
Any other reservations or concerns not listed above?