AHNS Mentorship Program: Mentor Application AHNS Mentorship Program – Mentor Application Name(Required) First Middle Last Institution(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Gender(Required) Age(Required) 30-40 41-50 51-60+ 61+ What is your degree?(Required) DO MD PhD MD/PhD Do you have other advanced degrees? If so, please list: Name of Residency Program(Required) Name of Fellowship Program(Required) How many years ago did you complete your training?(Required) <5 5-10 11-15 16-25 25+ Specialty(Required) eg: ablative/ recon/ endo/ basic sciencePractice Setting (check all that apply)(Required) Academic Private practice – single physician Private practice – multi-physician Hospital based VA Other Other Practice Setting(Required) If Academic, what is your title? Fellow Instructor Assistant Professor Associate Professor Full Professor/Surgeon Have you ever served as a professional mentor?(Required) Yes No If selected, are you able to devote the next year to supporting your mentee on a minimum, quarterly basis?(Required) Yes No What is your expected time availability for the program?(Required) Monthly meetings Quarterly meetings If selected, would you prefer to mentor one or two mentees, or no preference?(Required) One Two No Preference Do you currently have other mentees?(Required) Yes No If you have current mentees, how many? Do you serve in an official role for your current mentees? Fellowship director Residents in my program Medical Students at my current institution Partners/colleagues in my practice Researcher in my lab Other Select the top 3 areas you can mentor in from the following list:(Required) Career development (eg. Promotion, contract negotiation) Research Goals Practice development Work and Outside-of-Work integration Transition to Practice Leadership Development Education of residents and or medical students Other Work and Outside-of-Work integration – Please specify if you are married, single, your race, if you have a young family, want to start a family, etc. so that we can match you to an appropriate mentee(Required) Other Mentor Area(Required) What is the most important quality of a good mentor? (Please pick only one)(Required) Approachable Well known in own field Well published Has own laboratory Compassionate Prepared Enthusiastic Willingness to sponsor my future efforts What is the most important quality of a good mentee? (Please pick only one)(Required) Motivation to succeed Time management Willingness to learn Respectful Clear communication Positive attitude Organized Personal Statement – Include a brief paragraph outlining why you wish to be a mentor and what you hope to gain from participating in this program. (500 words maximum)(Required)Please upload your CV(Required)Accepted file types: pdf, doc, docx, Max. file size: 100 MB.CommentsThis field is for validation purposes and should be left unchanged. Δ Share:FacebookTwitterLinkedIn