Pre-Program Skill Assessment Form (FPHR-C22)

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Section A. Applicant Details

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Gender(Required)

Male

Female

Prefer not to say

Date of Birth(Required)

First Author publications(Required)

None

One publication

Two publications

Three or more publications

Interested in Type of Research(Required)

Clinical research

Quality improvement

Medical education

Translational research

I am not doing research

Basic science research

I am not interested in research

Health services research

Any prior experience with research in past?(Required)

Yes

No

If yes, elaborate on your prior research experience(Required)

Attitude Intent to incorporate research into your careers.(Required)

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

What is your specific current research focus or interest, if any?

What are your career plans after completing the academic program, Fundamentals of Population Health Research (FPHR) with FHTS?(Required)