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*

Pharmacist

Current Primary Role (please select ONE)*

Select

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?)

Send me a copy of my responses

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