How to Submit a CERA Proposal

Is Your Medical School Considered to Be Public or Private?

• Public
• Private

In What State/Province Is Your School Located?

This information will be aggregated into regions before data is disseminated.

How Long Have You Been in Your Current Clerkship Director Role?

How Many Total Years Have You Served as a Clerkship Director?

What Is Your Current Gender Identity? Select All That Apply

• Female/Woman
• Male/Man
• Genderqueer/Gender non-conforming
• Non-binary
• Choose not to Disclose
• Prefer to self-describe (please specify)

Which of the Following Best Defines Your Race or Ethnicity? Select All That Apply

• Hispanic/Latino/a/Spanish Origin
• American Indian/Alaska Native/Indigenous
• Asian
• Black/African American
• Native Hawaiian/Pacific Islander
• White
• Middle Eastern/North African

I Self-Identify as Underrepresented in Medicine.

• No
• Yes

For URM Questions we used the following definition from AAMC:
“Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population (Black/African-American, Hispanic/Latino/of Spanish Origin, American Indian/ Alaska Native/Indigenous, Native Hawaiian/other Pacific Islander, and certain Asian ethnicities).”

Do You Have a Physician's Degree (e.g., MD/DO)?

• Yes
• No

If Yes, What Year Did You Graduate From Residency Training?

If No, What Year Were You Awarded Your Highest Level of Degree, Such as PhD?

What Percentage of Your Time Is Protected to Serve as Clerkship Director?

How Many Students Are There Typically in One Class at Your School?

Is the Family Medicine or Primary Care Clerkship Mandatory for All Medical Students?

• Yes
• No

In Which Year or Years of Training Are Medical Students Expected to Participate in This Clerkship?

Please do not count medical students who, for health or academic reasons, are out of phase with their class. Please do mark ALL years that apply.

• M1
• M2
• M3
• M4

Please Select the Design of Your Clerkship.

• Block only (defined as sequential weeks of full-time study)
• Longitudinal only
• Both block and longitudinal

How Many Weeks Does Your Family Medicine Clerkship Last?

• Fewer than 3
• 3
• 4
• 5
• 6
• 7
• 8
• More than 8 weeks (please specify)

How Many Weeks Does Your Longitudinal Family Medicine Clerkship Last (Overall Duration)?

Adding Together All the Curricular Time, How Many Weeks in Total Is Your Longitudinal Family Medicine Clerkship?

• Fewer than 3
• 3
• 4
• 5
• 6
• 7
• 8
• More than 8 weeks (please specify)

This next set of questions relates to a school that has two different tracks for medical students, one with sequential weeks of full-time study (block rotation) and the other with a longitudinal format.

Please Estimate the Percentage of Students Assigned to Each of the Two Tracks.

• Block:
• Longitudinal:

How Many Weeks Does the Block Portion of Your Clerkship Last?

• Fewer than 3
• 3
• 4
• 5
• 6
• 7
• 8
• More than 8 weeks (please specify)

How Many Weeks Does the Longitudinal Portion of Your Clerkship Last?

Adding Together All the Curricular Time, Calculate Approximately How Many Weeks in Total Your Longitudinal Family Medicine Clerkship Lasts

• Fewer than 3
• 3
• 4
• 5
• 6
• 7
• 8
• More than 8 weeks (please specify)

Recognized by organizations like the Liaison Committee for Medical Education, Regional Medical Campuses are geographically separate from the main campus, typically have students spend a block of time on site, and have an administrative structure with official ties to the Dean's Office.

How many Regional Medical Campuses does your school have?

• 0%
• 1-25%
• 26-50%
• 51-75%
• 76-100%

What Percentage of Your Clerkship Students Get Sent to a Regional Medical Campus?

• 0%
• 1–25%
• 26–50%
• 51–75%
• 76–100%

What Percentage of Students in Your Family Medicine Clerkship Spend at Least Half of the Rotation Time in the Practice of a Community Preceptor?

• 0%
• 1–25%
• 26–50%
• 51–75%
• 76–100%

Please Estimate the Percentage of Family Medicine Community Preceptors Whom You Pay to Teach Clerkship Students

• 0%
• 1–25%
• 26–50%
• 51–75%
• 76–100%

For Those Preceptors Whom You Pay, Please Estimate How Much You Pay Per Week for Each Clerkship Student

What Percentage of Your Students Go to Clerkship Sites That Require Overnight Stays?

• 0%
• 1–25%
• 26–50%
• 51–75%
• 76–100%

After Any Centralized Orientation Activities at the Start of the Clerkship and Before Any End-of-Clerkship Assessment Events, How Many Times Are Your Clerkship Students Required to Return to Campus for Activities and/or Instruction?

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• More than 10

What Is Your Current Gender Identity? Select All That Apply

• Female/Woman
• Male/Man
• Genderqueer/Gender non-conforming
• Non-binary
• Choose not to Disclose
• Prefer to self-describe (please specify)

Which of the Following Best Defines Your Race or Ethnicity? Select All That Apply

• Hispanic/Latino/a/Spanish Origin
• American Indian/Alaska Native/Indigenous
• Asian
• Black/African American
• Native Hawaiian/Pacific Islander
• White
• Middle Eastern/North African

I Self-Identify as Underrepresented in Medicine.

• No
• Yes

For URM Questions we used the following definition from AAMC:
“Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population (Black/African-American, Hispanic/Latino/of Spanish Origin, American Indian/ Alaska Native/Indigenous, Native Hawaiian/other Pacific Islander, and certain Asian ethnicities).”

How Old Are You?

• 20–29 years old
• 30–39 years old
• 40–49 years old
• 50–59 years old
• 60–69 years old
• 70+ years old

What Degrees Have You Earned? Select All That Apply

• DNP
• DO
• EdD
• LISW
• MBA
• MD
• MEd
• MPH
• MSW
• PharmD
• PhD
• RN
• Other Master’s Degree (please specify)

How Long Have You Been in Your Current Department Chair Role?

How Many Total Years Have You Served as a Department Chair?

Please Describe the Type of Residency Within Your Department.

• University based
• Community-based, University Affiliated
• Community-based, Non-affiliated
• Military
• No residency
• Other (please specify)

In What State Is Your Department Located?

This information will be grouped into geographic regions before dissemination.

What Is the Approximate Size of the Community in Which Your Department Is Located?

• Less than 30,000
• 30,000–75,000
• 75,001–150,000
• 150,001–500,000
• 500,001–1 million
• More than 1 million

How Many Full-Time FTEs Does Your Department Have?

Note: Because the CERA General Member Survey may have either a general or targeted audience, these are only example questions. Final core questions will be determined by the accepted researchers.

What Is Your Highest Degree Earned?

• EdD
• DNP
• DO
• MD
• MD/PhD or DO/PhD
• PhD
• Other doctoral level
• Other nursing level
• Master’s level
• Bachelor’s level

In What Year Did You Earn Your Highest Degree?

In What State Is Your Department Located?

This information will be grouped into geographic regions before dissemination.

What Is the Approximate Size of the Community in Which Your Department Is Located?

• Less than 30,000
• 30,000–75,000
• 75,001–150,000
• 150,001–500,000
• 500,001–1 million
• More than 1 million

Is Your Institution a(n)…?

• Allopathic medical school
• Osteopathic medical school
• Not at a medical school

Does Your Institution Have…?

• Multiple residencies including family medicine
• Multiple residencies not including family medicine
• Only a family medicine residency
• No residency education

How Old Are You?

• 20–29 years old
• 30–39 years old
• 40–49 years old
• 50–59 years old
• 60–69 years old
• 70+ years old

What Is Your Current Gender Identity? Select All That Apply

• Female/Woman
• Male/Man
• Genderqueer/Gender non-conforming
• Non-binary
• Choose not to Disclose
• Prefer to self-describe (please specify)

Which of the Following Best Defines Your Race or Ethnicity? Select All That Apply

• Hispanic/Latino/a/Spanish Origin
• American Indian/Alaska Native/Indigenous
• Asian
• Black/African American
• Native Hawaiian/Pacific Islander
• White
• Middle Eastern/North African

I Self-Identify as Underrepresented in Medicine.

• No
• Yes

For URM Questions we used the following definition from AAMC:
“Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population (Black/African-American, Hispanic/Latino/of Spanish Origin, American Indian/ Alaska Native/Indigenous, Native Hawaiian/other Pacific Islander, and certain Asian ethnicities).”