FSA Selection Form Internal Medicine FSA Selection Form We are delighted you're interested in an IM FSA!Please fill out this survey and you will be assigned a FSA in the subsequent weeks. All responses to this survey will be kept in strict confidence. Name* First Last Email* Expected year of graduation?* If known, who is your SAO Dean? Degrees Expected on Graduation- MD/PHD, MBA, MPH, JD What, if any, regions of the country are you specifically interested in for residency training? If you have communicated with an Internal Medicine faculty about being your FSA, please indicate who: Do you have a request for a specific IM faculty member to be your FSA? Sonia Anathakrishnan Alex Bachorik Shielah Bernard Katy Bockstall Ryan Chippendale Ricardo Cruz Radha Govindraj Rob Lowe Eric Marks Juhee McDougal Katie Modzelewski Craig Noronha Tom Ostrander Alex Pipilas Purva Ranchal Joe Rencic Catherine Rich Margot Rogers Hallie Rozansky Lauren Stern Asher Tulsky Ashish Upadhyay Other You may choose up to 5If you selected "Other," please indicate your FSA preference below: Are you couples matching? Wil you require a VISA during residency training?* Please indicate if you failed STEP 1, or if your STEP 2 score was < 220 Any fails or remediations in Year 1, 2, or 3? Or, any PASS grades on any clerkship? Do you have an internal medical specialty you are interest in pursuing fellowship in and if so, what specialty? Are you interested in a internal medicine primary care residency? Is there anything else you would like us to know at this point?