I'M READY Intern Preparation Course Enrollment Form

Whitetulip Intern Preparation Course
Completion of this survey is required for program enrollment and evaluation; however, some questions are optional and may be skipped. Your responses will remain confidential and will be analyzed and reported only in anonymous, aggregated form for statistical analysis, program improvement, and potential scholarly presentations to support future International Medical Graduates (IMGs) transitioning into U.S. residency.
Name

First NameLast Name
Please create your code using which will be used to track your attendance if you wish to receive a certificate

First names initial+last names initial+your birth month(2 digits)+last 2 digits of your phone number

Example:
Name: Mary Smith
Birth Month: May (05)
Phone number xxxxx-83

Code: MS0583
Your Code
Email
example@example.com
Medical School Graduation Year
Country of Origin
Country of Medical School (if different than country of origin)
My speciality is

Other
Which Residency Program did you match to?
Which state your Residency Program is in?
How did you hear about the program?

Other
How do you define your clinical experience in US
How long have you lived in US?
How familiar are you with health care system in US? 1 = Not familiar at all, 4 = Moderately familiar, 7 = Very familiar

1

2

3

4

5

6

7

1 is , 7 is
How familiar are you with the role of multi-disciplinary team members in US health care (social workers, case managers, respiratory therapists, dieticians, etc)? 1 = Not familiar at all, 4 = Moderately familiar, 7 = Very familiar

1

2

3

4

5

6

7

1 is , 7 is
Have you ever used any electronic medical record (EMR) system prior to residency?

Other
How confident are you using electronic medical system in US and navigating it (writing daily progress notes, placing orders, admitting and discharging) 1 = Not confident at all, 4 = Moderately confident, 7 = Very confident

1

2

3

4

5

6

7

1 is , 7 is
Please rate your confidence in presenting a patient during rounds? 1 = Not confident at all, 4 = Moderately confident, 7 = Very confident

1

2

3

4

5

6

7

1 is , 7 is
Please rate your confidence in creating a full "assessment and plan" 1 = Not confident at all, 4 = Moderately confident, 7 = Very confident

1

2

3

4

5

6

7

1 is , 7 is
Rate your confidence level practicing as an intern at your residency program on July 1st (taking care of patient admissions, daily rounds, discharge by senior/attending supervision) 1 = Not confident at all, 4 = Moderately confident, 7 = Very confident

1

2

3

4

5

6

7

1 is , 7 is
Should be Empty:

Whitetulip Intern Preparation Course