Outlist Entry Form

Thank you for your interest in the Feinberg OutList. We recommend allowing 5-10 minutes to complete this survey.


Please note that this questionnaire is public and voluntary. Filling it out will put you on the OutList which is published on the Office of Health Equity website.


The Feinberg School of Medicine understands the personal and sensitive nature of this information and is committed to encouraging and sustaining a community that is free from discrimination and harassment.


You may choose to modify your submission at any time by resubmitting this form or emailing Gracen Koepele at gracen.koepele@northwestern.edu.


Thank you for supporting these efforts to make Feinberg a more inclusive environment.



Sincerely,

Office of Health Equity

Feinberg School of Medicine

Northwestern University

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This will allow us to automatically keep the OutList updated and current with member information (e.g., promotions, appointments, departures, etc.)

If you wish to be listed on the OutList by a name different than the one entered above, please write your full name as you would like it to appear here.

Primary role at Northwestern*

If this information is not applicable, please skip

If this information is not applicable, please skip

For example: Associate Professor of Pediatrics; PGY-2 Surgery Resident; Adjunct Professor at Kellogg School of Management, etc.

If you are interested in mentoring a Northwestern Medicine learner (i.e., School of Medicine student or NM resident) or early-career professional, please indicate which types of mentorship you would be willing to provide? (Select all that apply)

Potential areas of expertise may include any of the following: Non-clinical: Creating an LGBTQ+ affirming work environment, ally/upstander training, special topics related to LGBTQ+ People of Color (i.e., Queer and Transgender People of Color, "QTPOC"), LGBTQ+ community engagement research, best practices for gender transition in the workplace. Clinical: Hormone replacement therapy, LGBTQ+ couple's therapy, gender affirmation surgery, transition counseling, LGBTQ+ inclusive fertility, cancer screening & treatment, HIV prevention (i.e., PrEP/PEP) & treatment, etc.)

We welcome your feedback including any suggestions, comments, and questions that you may have about this survey or the OutList.

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