STUDENT/RESIDENT PROFILE FORM

All students and residents involved in clinical experiences at Unity: Please complete the following profile form and click on "Submit Now" to e-mail it directly. Submitting this form allows Unity and AHEC to document and track the teaching activities occurring at Unity sites. We also encourage you to visit the AHEC website, which contains important information and a brief curriculum for students and residents working at community sites.

 

Washington DC Area Health Education Center

Community Based Training- Profile Form

Report Date:
STUDENT INFO
Name (Last, First)
 
E-mail Address:             
      
Race:
White    Black    Hispanic    Asian    Native American   Other   
Gender:
Male    Female   
Academic Status:

Student  1st   2nd   3rd  4th

Resident  1st   2nd   3rd  4th

Other    

Rotation Information:

Dates

Status

Begin:   End:   Required Elective
Sessions/Week:
(1 Session = half day)
 
Rotation/Course Name:
INSTITUTION INFORMATION
Educational Institution:
 Degree Program: (MD, Residency, PA, etc.)
Institution Contact Person:
 		Title of Contact Person:
 Phone No.:
PRECEPTOR INFORMATION
Name:
 Training Site:
Address:
 City, State:
 Zip Code:
Phone:
 Discipline of Preceptor
Please mark all that apply
FM   IM
Peds Other
ADDITIONAL COMMENTS

If you prefer to e-mail, fax, or send this via US Mail, it should be addressed to:
Tamekia McMahon, Volunteer Outreach Specialist
Unity Health Care, Inc.
1220 12th Street, SE
Suite 120
Washington, DC 20003
 ph. 202-715-7914
 fax 202-544-2714
e-mail:  ClinicalRotations@unityhealthcare.org