Response-O-Matic Form

 

Membership Form

The Medical Spouse Network is a support organization created
by medical spouses for medical spouses.
We have no membership dues.
To join the MSN and begin receiving our print-based newsletter,
please fill out the membership information and survey.
If you have already completed the survey, please fill out the membership card section only!

Membership Form

 

First Name

Last Name

Mailing Address (Street, City, State, Zip)

How did you hear about The Medical Spouse Network?

Surviving Residency Survey

Your name:

Email address:

What is your spouse's training year?

Intern
PGY-2
PGY-3
PGYG-4+
Fellowship
Finished with Training!

 

What is your spouse's area of training? ie..Internal Medicine, Surgery, OB/Gyn, Family Practice...

 

What is the name of the program and the location?

How many hours a week is/was your spouse typically at the hospital?

30-40
41-50
51-60
61-70
71-80
81-90
91-100
100+

Does/Did the hospital have a support group for spouses?

Yes
No
Don't Know

Would you recommend this program to other spouses?

Yes
No
Unsure

 

What are/were the best rotations at this program for you and your spouse?

 

What are/were the worst rotations at this program for you and your spouse?

 

Does/Did the Program provide medical and dental insurance?

Medical
Dental
Both
Neither

 

Briefly describe the surrounding communities ie, shopping, entertainment, schools

 

What additional things would you like other spouses to know about this program? All comments in this survey are anonymous and no names or identifying information will be posted.

 

 
iMSN Membership Information