2009 FMIG Survey Medical School Information Name of Medical School Family Medicine Interest Group name FMIG web site URL Month that new student leaders are selected/elected FMIG Primary Faculty Advisor-Physician Name: Title: Mailing address: City: State: Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip: E-mail: Number of years serving as advisor: May we register your primary faculty advisorfor the FMIG Faculty Advisor Listserv hosted by the AAFP FMIG Network? Yes (be sure to include e-mail address above) No FMIG Faculty Advisor or Support Staff - Non-Physician Name: Title: Mailing address: City: State: Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip: E-mail Address Number of years serving as advisor May we register your your non-physican faculty advisor or support staff for the FMIG Faculty Advisor Listserv hosted by the AAFP FMIG Network? Yes (be sure to include email address above) No FMIG Primary Student Leader Contact Name: Title: Mailing address: City: State: Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip: E-mail: Is the primary student leader contact an AAFP student member? Yes No Class year of primary student leader M1 M2 M3 M4 May we register your primary student leader for the FMIG Student Leader Listserv hosted by the AAFP FMIG Network? Yes (be sure to include email address above) No FMIG Alternative Student Leader Contact Name: Title: Mailing address: City: State: Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip: E-mail: Class year of alternative student leader M1 M2 M3 M4 May we register your alternative student leader for the FMIG Student Leader Listserv hosted by the AAFP FMIG Network? Yes (be sure to include email address above) No AAFP Student Membership Coordinator Name: Title: Mailing address: City: State: Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip: E-mail: Class year of AAFP student membership coordinator M1 M2 M3 M4 Is the student membership coordinator a member of the FMIG? Yes No How many meetings did the FMIG host in the 08-09 academic year? Number of meetings How many meetings are planned for academic year 09-10? Number of meetings Does your FMIG track community service activities? Yes No Approximately how many hours of community service did your FMIG do last year? Number of hours Check the types of programming your FMIG will provide in the 09-10 academic year. Medical student career programming Structured mentoring program Medical student financial planning Clinical skills workshop Clinical education Discussion on current trends in family medicine Community service Social activities Residency fair Did your FMIG address content related to the Patient-Centered Medical Home (PCMH), such as EHRs, communication, multidisciplinary teams and chronic disease management last year? Yes No Unaware of the Patient-Centered Medical Home Will the FMIG address one or more elements of the Patient-Centered Medical Home in 09-10? Yes No How many FMIG meetings and events does the faculty advisor or faculty representative attend? All FMIG meetings and events Most FMIG meetings and events Some FMIG meetings and events Few FMIG meetings and events No FMIG meetings and events How many M4s are at your medical school? Number of M4s Number of M4s who matched into a family medicine residency Number of M4s who matched into a family medicine residency who were members of the FMIG Rate your interest group's level of student activity on campus. Participation by 75% or more of M1 & M2 students 50% to 74% of M1 & M2 students participate 25% to 49% of M1 & M2 students participate Less than 25% of M1 & M2 students participate No student interest Do you measure the success of the FMIG? Yes, what measures do you track? No How many students typically attend FMIG events (not leadership meetings)? 1-5 6-10 11-15 16-25 More than 25 Identify three strengths of your FMIG: 1) 2) 3) Identify one challenge for your FMIG that will be addressed this year. - With what FMIG/student interest issues does your FMIG need help? - Rate the value of the Virtual FMIG Web Site as a family medicine and FMIG resource. Very valuable Somewhat valuable Neutral Not very valuable Not valuable at all Not aware of Virtual FMIG Web site Estimate how much your FMIG will spend this year? <$1000 $1,001-$1,500 $1,501-$2,500 More than $2,500 What were the key sources of funding for the FMIG? FM department Dean's office AAFP constituent chapter Fundraising activities, i.e., t-shirt sales Residency fair Individual donations FMIG funding initiative Other Estimate what proportion of M3 & M4 FMIG members that participate in two or more FMIG events during the year: None 1-25% 26% to 50% More than 50% Compared to last year, is the number of FMIG members expressing a high level of interest in family medicine... Increasing About the same Decreasing Don't know What percentage of students in your FMIG are members of the AAFP? 100% 75-99% 50-74% 25-49% Less than 25% Don't know Do you know who your FMIG Network Regional Coordinator is? Yes No Do you receive communications about the AAFP through him or her? Yes No Don't know Does your FMIG sponsor residency fairs? Yes, what month(s): No How many different residency programs participated in a collaborative activity with your FMIG? None One Two Three Four Five More than five Have you noticed a change in the perception of the value of AAFP student membership since the American Family Physician journal was changed to online-only for student members? Yes No
Name of Medical School Family Medicine Interest Group name FMIG web site URL Month that new student leaders are selected/elected
Name: Title: Mailing address: City: State: Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip: E-mail: Number of years serving as advisor:
Yes (be sure to include e-mail address above) No
FMIG Faculty Advisor or Support Staff - Non-Physician
Name: Title: Mailing address: City: State: Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip: E-mail Address Number of years serving as advisor
Yes (be sure to include email address above) No
FMIG Primary Student Leader Contact
Name: Title: Mailing address: City: State: Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon (Click here to choose) Zip: E-mail:
Yes No
Class year of primary student leader
M1 M2 M3 M4
May we register your primary student leader for the FMIG Student Leader Listserv hosted by the AAFP FMIG Network?
FMIG Alternative Student Leader Contact
May we register your alternative student leader for the FMIG Student Leader Listserv hosted by the AAFP FMIG Network?
AAFP Student Membership Coordinator
Is the student membership coordinator a member of the FMIG?
How many meetings did the FMIG host in the 08-09 academic year?
Number of meetings
Approximately how many hours of community service did your FMIG do last year?
Number of hours
Medical student career programming Structured mentoring program Medical student financial planning Clinical skills workshop Clinical education Discussion on current trends in family medicine Community service Social activities Residency fair
Did your FMIG address content related to the Patient-Centered Medical Home (PCMH), such as EHRs, communication, multidisciplinary teams and chronic disease management last year?
Yes No Unaware of the Patient-Centered Medical Home
Will the FMIG address one or more elements of the Patient-Centered Medical Home in 09-10?
How many FMIG meetings and events does the faculty advisor or faculty representative attend?
All FMIG meetings and events Most FMIG meetings and events Some FMIG meetings and events Few FMIG meetings and events No FMIG meetings and events
How many M4s are at your medical school?
Number of M4s Number of M4s who matched into a family medicine residency Number of M4s who matched into a family medicine residency who were members of the FMIG
Participation by 75% or more of M1 & M2 students 50% to 74% of M1 & M2 students participate 25% to 49% of M1 & M2 students participate Less than 25% of M1 & M2 students participate No student interest
Do you measure the success of the FMIG?
Yes, what measures do you track? No
How many students typically attend FMIG events (not leadership meetings)?
1-5 6-10 11-15 16-25 More than 25
Identify three strengths of your FMIG:
1) 2) 3)
-
Very valuable Somewhat valuable Neutral Not very valuable Not valuable at all Not aware of Virtual FMIG Web site
Estimate how much your FMIG will spend this year?
<$1000 $1,001-$1,500 $1,501-$2,500 More than $2,500
What were the key sources of funding for the FMIG?
FM department Dean's office AAFP constituent chapter Fundraising activities, i.e., t-shirt sales Residency fair Individual donations FMIG funding initiative Other
Estimate what proportion of M3 & M4 FMIG members that participate in two or more FMIG events during the year:
None 1-25% 26% to 50% More than 50%
Compared to last year, is the number of FMIG members expressing a high level of interest in family medicine...
Increasing About the same Decreasing Don't know
What percentage of students in your FMIG are members of the AAFP?
100% 75-99% 50-74% 25-49% Less than 25% Don't know
Do you know who your FMIG Network Regional Coordinator is?
Do you receive communications about the AAFP through him or her?
Yes No Don't know
Does your FMIG sponsor residency fairs?
Yes, what month(s): No
How many different residency programs participated in a collaborative activity with your FMIG?
None One Two Three Four Five More than five
Have you noticed a change in the perception of the value of AAFP student membership since the American Family Physician journal was changed to online-only for student members?
