NSU-COM Exit Questionnaire

All fields marked with a * are required

Personal Information
*First Name:
*Last Name:
*Address:
*City:
*State:
*Zipcode:
*Email:
Phone:	( ) -
Florida Resident?	Yes No
Are you attending an internship / residency?
	Yes No
if you responded YES, proceed to Part I. Otherwise proceed to Parts II & III**.

Part II: Scholarship / Loan Repayment Information

Please complete, if you have ever (or plan to) apply for a HHSC or FHSC Scholarship or loan repayment. Click next to the applicable response(s).
	National Health Service Corps (NHSC) Scholarship
	NHSC Loan Repayment
	Florida Health Service Corps (FHSC) Scholarship
	FHSC Loan Repayment

Applied and Already Awarded		Applied and Did Not Get Award

Part III: Grad. Med. Stdts NOT Entering Int./Res. Next Year (FL. Res. Only)

Where will you be located during the next year? South Florida Central / North Florida Out of State Undecided

Will you be working as a physician? Yes No Undecided

Anticipated position or job title:

Do you plan on practicing in an underserved / rural area?
Yes No Undecided/Unknown

Will you be pursuing further education?
Yes No Undecided/Unknown

If yes, please name the degree you are pursuing and the institution you will be attending:
Degree:
Institution:

March 27, 2008

NSU-COM Exit Questionnaire

Personal Information