Q1. Name:

Email address:

I am male    female

I Intercalated in International Health: Yes  No

Region of study/Deanery: (e.g. Yorkshire and Humber)

Describe your current stage of medical training:
In Pre-Registration Year Within 12 Months of Qualification More than 12 Months from Qualification

Q2.     I would apply for a FY2 post in International Health (Please select an option)
Strongly Agree Agree Don't Know Disagree Strongly Disagree  

Q3.     I would like the following specialities to appear on the same FY2 rotation as International Health.

(Please rate from 0 to 5, where 0 is not interested at all and 5 is extremely interested, top-priority!)

Obstetrics and Gynaecology
0 1 2 3 4 5

Infectious Diseases
0 1 2 3 4 5  

G U Medicine (GUM)
0 1 2 3 4 5

GP
0 1 2 3 4 5

Accident and Emergency
0 1 2 3 4 5

Cardiology
0 1 2 3 4 5

Respiratory Medicine
0 1 2 3 4 5

General Surgery
0 1 2 3 4 5

Paediatrics
0 1 2 3 4 5

Anaesthestics
0 1 2 3 4 5

Diabetes
0 1 2 3 4 5

Urology
0 1 2 3 4 5

Neurology
0 1 2 3 4 5

Public Health
0 1 2 3 4 5

Psychiatry
0 1 2 3 4 5

Oncology and Palliative Care
0 1 2 3 4 5

Dermatology
0 1 2 3 4 5

Orthopaedics
0 1 2 3 4 5

Other: (please specify) 0 1 2 3 4 5  

Q4.     I would be prepared to move deaneries to complete a FY2 post including Interantional Health.

Strongly Agree Agree Don't Know Disagree Strongly Disagree

Finally, please use this space for any other comments or suggestions: