Exit this survey >> Mentor of the Year 2011 1. Default Section 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). Question Title * 1. Please provide the contact information for the person who is being nominated for Mentor of the Year. Name: * Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title * 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. Name: * Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title * 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. 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) Question Title * 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. Question Title * 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. Question Title * 6. 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 Question Title * 7. 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? Question Title * 8. 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 Question Title * 9. How long did the mentoring relationship last? For less than a year For one to five years For more than five years Question Title * 10. Has the experience of you being mentored led you to mentor someone else? Yes No Too soon to tell Question Title * 11. 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 Question Title * 12. What impact has the nominee had on you personally? Please try to limit your response to this question to 200 words or less. Done >>