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IPE Immersion 1 Small Group Facilitator
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Date Selection:
Thursday Afternoon, January 19, 2023 1pm-3pm
Name
Full Name.
Work Email
Campus Address
Work Telephone
Role
Choose One
Faculty
Fellow
Resident
Other
Department/Discipline
Please choose one
Anatomy & Cell Biology
Anesthesia
Biochemistry & Molecular Biology
Biostatistics
Cellular & Integrative Physiology
Dermatology
Emergency Medicine
Family Medicine
Interdisciplinary/Other
Internal Medicine
Medical & Molecular Genetics
Microbiology & Immunology
Neurology
Neurosurgery
Obstetrics/Gynecology
Ophthalmology
Orthopedics
Otolaryngology
Pathology & Laboratory Medicine
Pediatrics
Pharmacology & Toxicology
Physical Medicine & Rehab
Psychiatry
Radiation Oncology
Radiology & Imaging Sciences
Surgery & Surgical Subspecialties
Urology
Other Role if necessary
Do you currently have a faculty appointment with the IU School of Medicine?
Do you currently have a faculty appointment with the IU School of Medicine?
Yes
No
Name of Clinical Assistant/Scheduler
Please note: clinical assistant/scheduler will be copied on confirmation email.
Clinical Assistant Work Email
Submit
Cancel