Alda Medical Experience™ Immersion 2019
We are now accepting applications for our two-day Alda Medical Experience™ Immersion 2019 events. If accepted, participation is required for the entire two-day experience.

August 5-6, 2019 at the Hilton Garden Inn Stony Brook, Stony Brook, NY
October 7-8, 2019 at the SUNY Global Center, New York, NY

Visit aldacenter.org/medical-immersion for more information.

Name *
Your answer
E-mail *
Your answer
Institution *
Your answer
Which program dates are you applying for? *
Required
Do you have any restrictions (e.g. dietary, physical) that we should be aware of?
Your answer
1. Please provide your management title(s): *
Your answer
2. How did you learn of this program? *
Your answer
3. Describe your health care organization:
Its purpose; its services and patients; several measures of its size (e.g., annual budget, revenues, expenditures, # employees, patients or beds); medical school affiliation (if any)
Your answer
4. Please describe your role in the health care organization, including current responsibilities in each of these areas: Academic, Research, Clinical, Other
Your answer
5. List the top three management challenges you are facing: *
(limit response to 350 characters including spaces)
Your answer
6. Provide the number and type of individuals or groups you supervise as well as the number of patients (e.g., beds, practices, etc.) in your service: *
Your answer
7. Name, title/position of individual(s) to whom you report:
Your answer
8. Names of principal committees on which you sit:
Your answer
9. Program fee will be paid by (Name, Email, Institution):
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Stony Brook University. Report Abuse - Terms of Service