{"id":265,"date":"2019-02-12T11:59:53","date_gmt":"2019-02-12T16:59:53","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/im-student-education\/?page_id=265"},"modified":"2020-02-28T18:03:42","modified_gmt":"2020-02-28T23:03:42","slug":"fsa-selection-form","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/im-student-education\/resources\/fsa-selection-form\/","title":{"rendered":"FSA Selection Form"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Internal Medicine FSA Selection Form<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/im-student-education\/wp-json\/wp\/v2\/pages\/265' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_1_18\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><h2 class=\"gsection_title\">We are delighted you&#039;re interested in an IM FSA!<\/h2><div class='gsection_description' id='gfield_description_1_18'>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. <\/div><\/li><li id=\"field_1_14\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_14'>\n                            \n                            <span id='input_1_14_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.3' id='input_1_14_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_14_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_14_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_14.6' id='input_1_14_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_14_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\"><label class='gfield_label gform-field-label' for='input_1_2' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_3\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\"><label class='gfield_label gform-field-label' for='input_1_3' >Expected year of graduation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_15\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\"><label class='gfield_label gform-field-label' for='input_1_15' >If known, who is your SAO Dean?<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_4\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\"><label class='gfield_label gform-field-label' for='input_1_4' >Degrees Expected on Graduation- MD\/PHD, MBA, MPH, JD<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_5\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\"><label class='gfield_label gform-field-label' for='input_1_5' >What, if any, regions of the country are you specifically interested in for residency training?<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_6\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\"><label class='gfield_label gform-field-label' for='input_1_6' >If you have communicated with an Internal Medicine faculty about being your FSA, please indicate who:<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_21\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Do you have a request for a specific IM faculty member to be your FSA?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_21'><li class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Sonia Anathakrishnan'  id='choice_1_21_1'   aria-describedby=\"gfield_description_1_21\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>Sonia Anathakrishnan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Alex Bachorik'  id='choice_1_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_2' id='label_1_21_2' class='gform-field-label gform-field-label--type-inline'>Alex Bachorik<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Shielah Bernard'  id='choice_1_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_3' id='label_1_21_3' class='gform-field-label gform-field-label--type-inline'>Shielah Bernard<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Katy Bockstall'  id='choice_1_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_4' id='label_1_21_4' class='gform-field-label gform-field-label--type-inline'>Katy Bockstall<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='Ryan Chippendale'  id='choice_1_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_5' id='label_1_21_5' class='gform-field-label gform-field-label--type-inline'>Ryan Chippendale<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='Ricardo Cruz'  id='choice_1_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_6' id='label_1_21_6' class='gform-field-label gform-field-label--type-inline'>Ricardo Cruz<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.7' type='checkbox'  value='Radha Govindraj'  id='choice_1_21_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_7' id='label_1_21_7' class='gform-field-label gform-field-label--type-inline'>Radha Govindraj<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.8' type='checkbox'  value='Rob Lowe'  id='choice_1_21_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_8' id='label_1_21_8' class='gform-field-label gform-field-label--type-inline'>Rob Lowe<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.9' type='checkbox'  value='Eric Marks'  id='choice_1_21_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_9' id='label_1_21_9' class='gform-field-label gform-field-label--type-inline'>Eric Marks<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.11' type='checkbox'  value='Juhee McDougal'  id='choice_1_21_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_11' id='label_1_21_11' class='gform-field-label gform-field-label--type-inline'>Juhee McDougal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.12' type='checkbox'  value='Katie Modzelewski'  id='choice_1_21_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_12' id='label_1_21_12' class='gform-field-label gform-field-label--type-inline'>Katie Modzelewski<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.13' type='checkbox'  value='Craig Noronha'  id='choice_1_21_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_13' id='label_1_21_13' class='gform-field-label gform-field-label--type-inline'>Craig Noronha<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.14' type='checkbox'  value='Tom Ostrander'  id='choice_1_21_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_14' id='label_1_21_14' class='gform-field-label gform-field-label--type-inline'>Tom Ostrander<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.15' type='checkbox'  value='Alex Pipilas'  id='choice_1_21_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_15' id='label_1_21_15' class='gform-field-label gform-field-label--type-inline'>Alex Pipilas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.16' type='checkbox'  value='Purva Ranchal'  id='choice_1_21_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_16' id='label_1_21_16' class='gform-field-label gform-field-label--type-inline'>Purva Ranchal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.17' type='checkbox'  value='Joe Rencic'  id='choice_1_21_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_17' id='label_1_21_17' class='gform-field-label gform-field-label--type-inline'>Joe Rencic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.18' type='checkbox'  value='Catherine Rich'  id='choice_1_21_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_18' id='label_1_21_18' class='gform-field-label gform-field-label--type-inline'>Catherine Rich<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.19' type='checkbox'  value='Margot Rogers'  id='choice_1_21_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_19' id='label_1_21_19' class='gform-field-label gform-field-label--type-inline'>Margot Rogers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.21' type='checkbox'  value='Hallie Rozansky'  id='choice_1_21_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_21' id='label_1_21_21' class='gform-field-label gform-field-label--type-inline'>Hallie Rozansky<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.22' type='checkbox'  value='Lauren Stern'  id='choice_1_21_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_22' id='label_1_21_22' class='gform-field-label gform-field-label--type-inline'>Lauren Stern<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.23' type='checkbox'  value='Asher Tulsky'  id='choice_1_21_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_23' id='label_1_21_23' class='gform-field-label gform-field-label--type-inline'>Asher Tulsky<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.24' type='checkbox'  value='Ashish Upadhyay'  id='choice_1_21_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_24' id='label_1_21_24' class='gform-field-label gform-field-label--type-inline'>Ashish Upadhyay<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.25' type='checkbox'  value='Other'  id='choice_1_21_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_25' id='label_1_21_25' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_21'>You may choose up to 5<\/div><\/li><li id=\"field_1_22\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><label class='gfield_label gform-field-label' for='input_1_22' >If you selected &quot;Other,&quot; please indicate your FSA preference below:<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_10\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><label class='gfield_label gform-field-label' for='input_1_10' >Are you couples matching?<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_11\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\"><label class='gfield_label gform-field-label' for='input_1_11' >Wil you require a VISA during residency training?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_12\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\"><label class='gfield_label gform-field-label' for='input_1_12' >Please indicate if you failed STEP 1, or if your STEP 2 score was  &lt; 220<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_16\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\"><label class='gfield_label gform-field-label' for='input_1_16' >Any fails or remediations in Year 1, 2, or 3? Or, any PASS grades on any clerkship?<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_8\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><label class='gfield_label gform-field-label' for='input_1_8' >Do you have an internal medical specialty you are interest in pursuing fellowship in and if so, what specialty?<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_9\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><label class='gfield_label gform-field-label' for='input_1_9' >Are you interested in a internal medicine primary care residency?<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_13\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\"><label class='gfield_label gform-field-label' for='input_1_13' >Is there anything else you would like us to know at this point?<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_23\"  class=\"gfield gfield--type-section gsection bu_google_recaptcha_section field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  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