AWIS Survey for Mentee
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1. Default Section
*
1
. Please enter your contact information.
Please enter your contact information.
Name:
Company:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code:
Country:
Email Address:
Phone Number:
*
2
. What is your current position?
What is your current position?
3
. What is your field of expertise?
What is your field of expertise?
*
4
. Please choose the highest level of education completed.
Please choose the highest level of education completed.
PhD Candidate
Postdoctoral Fellow
Graduate Student
PhD
MD
MA/MS
BA/BS
Other
5
. Please enter years of professional experience.
Please enter years of professional experience.
0-5
6-10
11-15
16-20
6
. What is your age group?
What is your age group?
21-30
31-40
41-50
51 and above
7
. Why are you interested in peer mentoring? (feel free to select more than one).
Why are you interested in peer mentoring? (feel free to select more than one).
Career development
Academic job track
Transitioning to industry
Getting started in industry
Career change exploration
Mid-career decisions
Challenges faced at work
Learning to network
Balancing work and family
Other
Other (please specify)
8
. Would you like to have your group consisting of peers who:
Yes
No
No preference
Are of your age group
*
Would you like to have your group consisting of peers who: Are of your age group Yes
Are of your age group No
Are of your age group No preference
Have similar professional background
Have similar professional background Yes
Have similar professional background No
Have similar professional background No preference
Have similar number of years of professional experience
Have similar number of years of professional experience Yes
Have similar number of years of professional experience No
Have similar number of years of professional experience No preference
Share your peer mentoring interests
Share your peer mentoring interests Yes
Share your peer mentoring interests No
Share your peer mentoring interests No preference
9
. Would you prefer to meet
Near home
Near work
Anytime
*
Would you prefer to meet Anytime Near home
Anytime Near work
During the day
During the day Near home
During the day Near work
After work
After work Near home
After work Near work
Weekends
Weekends Near home
Weekends Near work
10
. How often would you like to meet?
How often would you like to meet?
Once a month
Twice a month
Other
Other (please specify)
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