Starzl Academy Participant Form

The Starzl Academy provides career advancement opportunities for physician scientists in training. We would like to connect with you.

Name Name First Last
Email
Year you graduated from medical school
Are you currently in a residency, fellowship, or post-doctoral training program at Northwestern, or are you interested in applying to Northwestern for such training?

Are you currently in a residency, fellowship, or post-doctoral training program at Northwestern, or are you interested in applying to Northwestern for such training? Currently In Interested In Applying
Your primary department affiliation
Which training areas are you interested in?
Research interest (check all that apply)

Research interest (check all that apply) Basic Basic-translational Translational Clinical/outcomes Epidemiology Implementation Quality Other Other
The Starzl Academy is committed to developing a diverse and inclusive environment that is rewarding for all physician-scientists in training at Northwestern. To enhance diversity among our physician scientists in training, Starzl is planning fellow-to-faculty awards for underrepresented trainees (more details to come). Toward that goal, we are interested in collecting the following demographic data. Your answers to these questions are optional and confidential.
Racial/ethnic background (optional)

Racial/ethnic background (optional) Black/African Hispanic/Latino Native American Native Hawaiian or other Pacific Islander White Asian More than one Other Other
Are you enrolled in a tribe?

Are you enrolled in a tribe? Yes No Not sure
Please list tribal affiliation(s) here:
Have you or an immediate family member been primarily raised on or currently living on a reservation?

Have you or an immediate family member been primarily raised on or currently living on a reservation? Yes No
Gender (optional)

Gender (optional) Male Female Transgender Other Other
Disadvantaged background (optional; must meet 2 or more criteria as defined by the NIH)

Disadvantaged background (optional; must meet 2 or more criteria as defined by the NIH) Yes No
Do you identify as having a physical or mental disability (optional)?

Do you identify as having a physical or mental disability (optional)? Yes No