MSUCOM ALUMNI QUESTIONNAIRE
Please help us keep in touch with you. The information requested on this form will ensure that the college’s alumni files are up-to-date and accurate. We never share this information outside the MSUCOM and never sell it to commercial organizations. Thank you for your help.
Name at graduation (if different):
COM Class of:
About Your Practice:
Preferred Mailing Address:
Medically Underserved Areas/Populations are areas or populations designated by HRSA as having too few primary care providers, high infant mortality, high poverty and/or high elderly populations. Do you currently practice at least 50% of your time in a medically underserved community (MUC)? Please indicate the type of MUCs below. This information will be used in HRSA grant applications submitted by MSUCOM faculty.
Community Health Center
Migrant Health Center
Health Care for the Homeless
Public Housing Primary Care
National Health Service Corps sites
Rural Health Clinic, federally designated
Indian Health Service sites
Federally Qualified Health Centers
Primary Medical Care Centers
Shortage Areas (HPSAs)
Sites Designated by State Governor
State or Local Health Departments
How would you best describe your practice?
Other (please describe below)
Do you have any news that you would like us to share? This may include promotions, awards, job changes, etc.
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