LGBT Residency Directory Questionnaire

Please specify your confidentiality preference:

Allow AMSA members & LGBT-approved non-members access to my contact information
Do not directly provide my contact information to anyone

Contact/Personal Information
Name:
E-mail:
Gender:
Orientation: lesbian
gay
bisexual
straight
other =
Open about your sexual orientation
   at program? yes no N/A
   at medical school? yes no N/A
   at undergraduate? yes no N/A
I may be contacted about: More info on my school/program
Advice for premeds/medical students
Providing housing for premeds or 4th years
     visiting for interviews
    If yes to housing:
    Distance from school:
   
    Comments:
   

Program/School Information
Specialty:
    If Other:
Name of hospital or training program:
City of program:
State of program:
Medical school:
    If Other:
Year graduated:
LGBT atmosphere of your program/advice for med students
Your overall comfort level as a LGBT resident in your school:
Attitude toward LGBT patients:
Attitude toward LGBT physicians:
Attitude toward LGBT support staff (nurses, PAs, techs, etc.):
Attitude toward you personally:
How do you think "out" LGBT applicants to this program would be regarded?
Has your partner/date attended departmental functions? yes no N/A
  If so, how was your partner/date received?
Ease of access to LGBT related resources in your local or medical community:
Acceptance/prevalence of activities of LGBT interest in your local or medical community:
Your overall comfort level as a LGBT person in the local community:
Specific LGBT-related details in your program
  Have you noticed any discrimination due to orientation? yes no N/A
  Number of other LGBT interns/residents that you know of in this program:
  Number of other LGBT physicians that you know of in this program:
  Number of other LGBT support staff that you know of in this program:
  My program offers the following LGBT resources: Check all that you are certain are true.
offers a couple's match with a same-sex partner
has a non-discrimination policy that includes sexual orientation
provides health benefits for domestic partners
has an LGBT employee or student organization
provides training on LGBT sensitivity in the workplace
provides training on the specific needs of LGBT patients
offers couples match for same-sex couples
Advice for application/residency
  I was OUT: On CV
On personal statement
During interview
None of the above
N/A
  If you were OUT on any portion of your application, did your interviewer ask you related questions? Please specify in the space provided. yes   no
Additional comments
  Additional comments about the program or the community:
  Any specific comments or advice for prospective applicants: