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What best describes the area of medicine in which you are trained? If you are trained in multiple specialties, please click “Add another area of medicine” on the righthand side of the page. If your specialty is not listed, please select “Other” in the dropdown menu.

Please describe the other area(s) of medicine in which you are trained:

How would you describe your current work status?

Please enter the month & year of your retirement.

Other. Please share any comments or questions.

Are you currently board certified?

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What is the date of your most recent board certification?

Is there anything else you'd like us to know about your board certification?

Briefly describe your clinical practice.

When were you last active in clinical practice?

Have you worked for or retired from Kaiser Permanente?

YesNo

Would you be interested in being a speaker for our medical education webinars?

YesNo

Please describe the topics or titles you wish to present. Note that the practical presentation should be catered to primary care providers working in resource-limited settings.

Race & Ethnicity

How did you initially hear about us?

Please enter the name of the person who referred you.

Yes, I would like to receive MAVEN Project news

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