Resident Alumni Registration Form - Baltimore Maryland MD

Harinath S Meda, M.D. , Anesthesiology, Board Certified

Franklin J Addison, M.D. , Family Practice

Resident Alumni Registration Form

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Resident Alumni Registration Form

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Resident Alumni - Join Our New Online Community
We are excited to begin building a special portion of our website dedicated to former resident alumni and we would like to know what you have been up to. Please take a moment to register your information with the Graduate Medical Education department in order to receive access to the web site once it is complete. If you like, your information will be added to our online alumni directory and will be searchable by other alumni.

All the information you provide is submitted to us securely and once completed, will only be available on a special secure area of the website created for other alumni to view. Your information will not be displayed to the general public, nor will it be sold or given to anyone else.

Website Registration
To receive access to this special section of the site and to officially register with our alumni departments, please take a moment to fill out the information below. You will be sent a login when this new portion of the website is complete.

The information requested below is being gathered for our alumni department. None of the information collected below will be published in the online directory unless you would like to be listed.

10. Your Residency Program While Here at Sinai *

* required info
1. First Name *
2. Last Name *
3. Date Of Birth
4. Address *
5. Apt
6. City *
7. State *
8. Zip *
9. Year of Graduation *
	Medicine Pediatrics OB /GYN Physical Medicine and Rehabilitation Surgery Pathology Radiology Ophtamology Rotation Dental Other Fellowship
If you choose Fellowship, please select a Fellowship from the following:

11. If Your Residency Was Medicine Was it Categorical or Preliminary? *
	Categorical Preliminary
12. Current Position *
13. Please Check The Appropriate Category of Your Current Profession *
	Academic Medical Center Medical School Employee Major Teaching Hospital Group Practice Solo Practice Managed Care Facility/Institution Government Practice / Veterans Hospital Hospital Based Physician No Longer Practicing Medicine
14. Current Employer
15. Employer Address
16. Employer City
17. Employer State
18. Employer Zip
19. Home Phone
20. Mobile Phone
21. Work Phone
22. Fax
23. Email Address *
24. Are You Board Certified? *	Yes No
25. If So Please List What Specialties You Are Board Certified In

26. Please List Your Subspecialties

27. Additional Certifications / Qualifications

28. Are You A Member Of Any Professional Organizations? If So Which Ones?

29. Do You Wish To Be Listed In Our Online Alumni Directory *
	Yes No
Sinai Hospital does not intend to use your information for any other purpose other then forming an alumni directory, and to receive general feedback on our residency programs. We do not intend to distribute or sell your information in any manner. The information below is for evaluation purposes only. None of the information collected below will be published in the online directory. Please take a moment to give us your feedback on the program and to let us know what you have been up to since your time here at Sinai.
30. Have You Received Any Additional Training?
	Yes No
31. If So Where At? For What?

32. Did You Have Any Additional Residencies or Fellowships AFTER Your Time here at Sinai
	Yes No
33. If So Please Describe

34. Please tell us How Well Did Your Training Here at Sinai Prepare You For Your Current Occupation

35. Any Comments On Your Experience Here At Sinai

36. Would you Recommend The Program To Prospective Residents? Why?

37. Do We have Your Authorization To Use Your Feedback From The Questions Above In Questions 1 Through 28
	Yes No I do not mind sharing my testimonials, but I would prefer to remain anonymous and not have my name listed
38. Do You Remain in Communication With Any Other Alumni?
	Yes No
39. If So Who?
40. Do You Have Any Comments or Suggestions on How We Can Improve Our Training Program Here at Sinai

41. Do You Have Any Suggestions or Ideas That You Would Like To See On Our Resident Alumni Website