ID Educator Network Roster

Use this form to submit a request to join the Infectious Diseases Educator Network (ID EN). Moderators will review requests within 1-3 days and will provide information on accessing the network. Please review the ID EN guidance document located here: https://ucsf.box.com/v/id-en-guidance

Yes! I'd like to join the ID Educator's Network and I've reviewed the Guidance Document linked above

Firstname

Lastname

Contact Email

Academic Institution or Other Affiliation

State

Phone

Profession

Current Primary Role (please select ONE)

Other Role description

Current educational activities: please check all of the following boxes that you feel apply to you

ID/ASP Advanced Experiential preceptor

ID/ASP Early Experiential (e.g. IPPE) Preceptor

ID/ASP Didactic Course Director

ID/ASP Didactic Group Instructor (e.g. Lecturer)

Residency Preceptor for ID/ASP (PGY-1 or PGY-2s)

PGY-2-ID or ID Fellowship Program Director

Educational Researcher/Scholar

Training completed: please indicate any of the following training programs you have completed.

Pharmacy PGY-1 Residency

Pharmacy PGY-2-ID Residency

Medical Residency

ID Fellowship

Stewardship Certificate (SIDP, MAD-ID, etc)

Other clinical postgraduate training (specify)

ID/ASP teaching interest (what excites you?)

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