American Academy of Dermatology Expert Resource Group on LGBTQ/Sexual and Gender Minority Health

Email Address *

Full Name/Preferred Name *

Level of Training *

AAD Member #* (*required for ERG membership!)

(Write “N/A” if not applicable)

Do you provide any dedicated LGBTQ specialty care?

Yes
Yes, but not a focus
No

What is your focus within LGBTQ/SGD dermatology?

if applicable

What are your LGBTQ/SGD research interests?

LGBTQ/SGD-related leadership positions/memberships

(leadership positions and/or memberships in groups, societies, and/or organizations)

Any other leadership positions in medicine

Please list any other leadership positions in organized medicine you hold (eg., local/state medical societies, dermatological societies, organized dermatology leadership (AAD, ASDS, SID), AMA, etc)

Interested in mentoring others?

Yes
Maybe, if time allows
No

(answer by attendings and residents only)

State

Current institution/practice setting

If other, please elaborate.

Name of current institution/practice

What is the name of your medical school?

Medical school graduation year

or anticipated graduation year

Name of your dermatology residency program?

(Write “N/A” if not applicable)

Residency graduation year

or anticipated graduation year

What was your assigned sex at birth?

If none of these describe you, please elaborate.

(optional)