Mentor of the Year 2011 Survey

The information that you post here can either be about how you serve as a mentor (self-nomination) or as someone who was mentored (nominating your mentor for the Mentor of the Year award).

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1. Please provide the contact information for the person who is being nominated for Mentor of the Year.

Please provide the contact information for the person who is being nominated for Mentor of the Year. Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

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2. Please provide the contact information for the person making the nomination for the Mentor of the Year, which, more than likely, is the individual completing the questions on this form (you) and was mentored by the person nominated.

Please provide the contact information for the person making the nomination for the Mentor of the Year, which, more than likely, is the individual completing the questions on this form (you) and was mentored by the person nominated. Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

3. How did you meet your mentor? Although more than one option may apply, choose the relationship most relevant to the mentoring aspect of your relationship with your mentor.

How did you meet your mentor? Although more than one option may apply, choose the relationship most relevant to the mentoring aspect of your relationship with your mentor. He/she is a colleague

He/she is a former or current college instructor

He/she is an employer

He/she is a representative of dental hygiene association

He/she is a family member

He/she is, or was, a fellow student at dental hygiene school

Other (please specify)

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4. State how long, and in what roles, your mentor has been a professional health care provider in dentistry? Please try to limit your response to approximately 75 words or less.

State how long, and in what roles, your mentor has been a professional health care provider in dentistry? Please try to limit your response to approximately 75 words or less.

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5. What are the nominee’s credentials and what impact has the nominee had on the dental hygiene profession? Please try to limit your response to this question to 100 words or less.

What are the nominee’s credentials and what impact has the nominee had on the dental hygiene profession? Please try to limit your response to this question to 100 words or less.

6. For how long have you been a dental hygienist?

For how long have you been a dental hygienist? I am a dental hygiene student

I have been practicing for less than five years

I have been practicing for 5-10 years

I have been practicing for 10-20 years

I have been practicng for more than 20 years

7. Did your mentor ... (More than one option may apply. Please choose the one that best describes the mentoring relationship)

Did your mentor ... (More than one option may apply. Please choose the one that best describes the mentoring relationship) help guide you with multiple face-to-face conversations, perhaps even on a daily basis in a dental practice?

help guide you through a long-distance relationship conducted primarily by telephone or e-mail?

help guide you through actions, not conversations - more as a role model observed?

8. What benefits did you derive from your mentor? (choose all that apply)

What benefits did you derive from your mentor? (choose all that apply) More knowledge about patient care

More self-confidence as a dental hygienist

More at ease in the dental setting where I worked

More focused on long-term career objectives

More comfortable about asking questions about dental care

More training on specific dental procedures

More proud of my career

9. How long did the mentoring relationship last?

How long did the mentoring relationship last? For less than a year

For one to five years

For more than five years

10. Has the experience of you being mentored led you to mentor someone else?

Has the experience of you being mentored led you to mentor someone else? Yes

No

Too soon to tell

11. In what type of setting is your experience as a dental hygienist currently being used?

In what type of setting is your experience as a dental hygienist currently being used? I work as a dental hygienist in a general dental practice

I work as a dental hygienist in a specialty practice

I work as a dental hygienist in a public health setting

I work as a dental hygienist in the dental manufacturing sector

I work as a dental hygienist in a dental school/dental hygiene school

I am self-employed as a dental hygienist, consultant, and/or trainer/lecturer

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12. What impact has the nominee had on you personally? Please try to limit your response to this question to 200 words or less.

What impact has the nominee had on you personally? Please try to limit your response to this question to 200 words or less.

Mentor of the Year 2011
Exit this survey >>

1. Default Section

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1. Please provide the contact information for the person who is being nominated for Mentor of the Year.

*
2. Please provide the contact information for the person making the nomination for the Mentor of the Year, which, more than likely, is the individual completing the questions on this form (you) and was mentored by the person nominated.

3. How did you meet your mentor? Although more than one option may apply, choose the relationship most relevant to the mentoring aspect of your relationship with your mentor.

*
4. State how long, and in what roles, your mentor has been a professional health care provider in dentistry? Please try to limit your response to approximately 75 words or less.

*
5. What are the nominee’s credentials and what impact has the nominee had on the dental hygiene profession? Please try to limit your response to this question to 100 words or less.

6. For how long have you been a dental hygienist?

7. Did your mentor ... (More than one option may apply. Please choose the one that best describes the mentoring relationship)

8. What benefits did you derive from your mentor? (choose all that apply)

9. How long did the mentoring relationship last?

10. Has the experience of you being mentored led you to mentor someone else?

11. In what type of setting is your experience as a dental hygienist currently being used?

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12. What impact has the nominee had on you personally? Please try to limit your response to this question to 200 words or less.

Mentor of the Year 2011Exit this survey >>

1. Default Section

*1. Please provide the contact information for the person who is being nominated for Mentor of the Year.

*2. Please provide the contact information for the person making the nomination for the Mentor of the Year, which, more than likely, is the individual completing the questions on this form (you) and was mentored by the person nominated.

3. How did you meet your mentor? Although more than one option may apply, choose the relationship most relevant to the mentoring aspect of your relationship with your mentor.

*4. State how long, and in what roles, your mentor has been a professional health care provider in dentistry? Please try to limit your response to approximately 75 words or less.

*5. What are the nominee’s credentials and what impact has the nominee had on the dental hygiene profession? Please try to limit your response to this question to 100 words or less.

6. For how long have you been a dental hygienist?

7. Did your mentor ... (More than one option may apply. Please choose the one that best describes the mentoring relationship)

8. What benefits did you derive from your mentor? (choose all that apply)

9. How long did the mentoring relationship last?

10. Has the experience of you being mentored led you to mentor someone else?

11. In what type of setting is your experience as a dental hygienist currently being used?

*12. What impact has the nominee had on you personally? Please try to limit your response to this question to 200 words or less.

Mentor of the Year 2011
Exit this survey >>

*
1. Please provide the contact information for the person who is being nominated for Mentor of the Year.

*
2. Please provide the contact information for the person making the nomination for the Mentor of the Year, which, more than likely, is the individual completing the questions on this form (you) and was mentored by the person nominated.

*
4. State how long, and in what roles, your mentor has been a professional health care provider in dentistry? Please try to limit your response to approximately 75 words or less.

*
5. What are the nominee’s credentials and what impact has the nominee had on the dental hygiene profession? Please try to limit your response to this question to 100 words or less.

*
12. What impact has the nominee had on you personally? Please try to limit your response to this question to 200 words or less.