Salutation== select == Mr. Ms. Miss Mrs. Mx. Dr. Hon. Prof.
First Name
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City
Prov/State== select == ==Canada== AB BC MB NB NL NS NT NU ON PE QC SK YT ==USA== AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MR MS MT NC ND NE NH NJ NM NN NV NY OH OK OR PA PL PO PR RI SC SD TN TT TX UT VA VI VT WA WI WV WY ==International== Other
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Select all that apply DVM MD or Equivalent PhD or Equivalent Other
If answered Other, please describe
Name of undergraduate institution
Undergraduate degree
Graduation date
Are you currently in progress or have completed this level of education/training? Y N
Name of medical/postgraduate institution
MD/postgraduate degree
MD/postgraduate graduation date
Are you current in progress or have completed this level of education/training? Y N
Internship/residency location #1
Inclusive dates
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GI followship training institution
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Completion year 1st Year 2nd Year 3rd Year 4th Year Other
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Primary work setting Clinical Research Other
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Clinical Academic Community
If answered clinical: in hospital Y N
If answered clinical: out hospital Y N
Principal field of activity/interest Clinical Practice Esophageal, Gastric & Duodenal Disorders Gastrointestinal Oncology Growth Development & Aging Hormones, Transmitters, Growth Factors & Their Receptors Imaging & Advanced Technology Immunology, Microbiology & IBD Intestinal Disorders Intestional Disorders Liver & Biliary Neurogasteroenterology & Motility Nutrition & Obesity Pancreatic Disorders Other
Indicate other activity/interest
MD Speciality/PhD Discipline
Please indicate the percentage of time you spend in each of the following professional activities (total should not exceed 100 percent)
Percent teaching== select == 0 10 20 30 40 50 60 70 80 90 100
Percent patient care== select == 0 10 20 30 40 50 60 70 80 90 100
Percent research basic or translational== select == 0 10 20 30 40 50 60 70 80 90 100
Percent administrative management== select == 0 10 20 30 40 50 60 70 80 90 100
Percent other activity== select == 0 10 20 30 40 50 60 70 80 90 100
Primary Professional/Training Activity Administrative Management Industry Patient Care Research: Basic of Translational Teaching Other
If answered Other to princial field of interest/activity, please describe
Subspecialty
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The association will only report summary demographic statistics. All individual responses will be kept confidential as required by federal PIPEDA regulations.
Which of the following BEST describes your ethnic background? Check all that appy Arab (Saudi Arabian, Palestinian, Iraqi, etc) Black/African/Caribbean Indigenous (Inuit/First Nations/Métis) Jewish (Ashkenazi, Sephardic, Mizrahi, etc) Latin American (Hispanic or Latino) South Asian (East Indian, Sri Lankan, etc) Southeast Asian (Chinese, Japanese, Korean, Vietnamese, Cambodian, Filipino, etc) West Asian (Iranian, Afghani, etc) White/European Prefer not to answer Other
Gender== select == Female Male Non-Binary Prefer not to answer
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Trainees and International Trainee membership - a letter from your program director (for residents and fellows) or your supervisor (for basic science trainees).
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