SAMBA Mentorship Survey
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1. SAMBA Mentorship Survey
*
1
. Please complete the section below:
Please complete the section below:
Name:
Institution:
City/Town:
State:
Email Address:
2
. Please indicate your age
Please indicate your age
30-40years,
41-55years,
56-65years,
older than 65years
3
. Did you receive fellowship training in a subspecialty?
Did you receive fellowship training in a subspecialty?
yes
no
Specify
4
. How long have you been practising anesthesiology?
How long have you been practising anesthesiology?
less than 10 years
10-20 years
21-30 years
more than 31 years
5
. Indicate the type of anesthesia practice:
Indicate the type of anesthesia practice:
Academic practice
Private practice - Hospital based
Private practice - Ambulatory Surgery Center
Private practice - Office Based Anesthesia
6
. What is your academic rank?
What is your academic rank?
Professor
Associate professor
Assistant professor
Instructor
7
. Do you hold an administrative position in your hospital?
Do you hold an administrative position in your hospital?
yes
no
Specify
8
. Please indicate if you are an officer in any of the following professional organization:
Please indicate if you are an officer in any of the following professional organization:
ASA
SAMBA
Local Anesthesiology Society
9
. Have you had a formal mentor in the past?
Have you had a formal mentor in the past?
yes
no
10
. Have you been a mentor in the past?
Have you been a mentor in the past?
yes
no
11
. How many SAMBA members are you currently mentoring?
How many SAMBA members are you currently mentoring?
none
1
2
3
more than 3
12
. Are you willing to serve as a mentor?
Are you willing to serve as a mentor?
yes
no
13
. I am willing to provide guidance regarding academic practice in anesthesiology.
I am willing to provide guidance regarding academic practice in anesthesiology.
yes
no
14
. I am willing to provide guidance regarding private practice in anesthesiology.
I am willing to provide guidance regarding private practice in anesthesiology.
yes
no
15
. I am willing to provide assistance regarding research issues.
I am willing to provide assistance regarding research issues.
yes
no
16
. I am willing to provide advice regarding manuscript publication.
I am willing to provide advice regarding manuscript publication.
yes
no
17
. I am willing to provide guidance regarding work/life issues.
I am willing to provide guidance regarding work/life issues.
yes
no
18
. I am willing to provide guidance regarding time management
I am willing to provide guidance regarding time management
yes
no
19
. I am willing to provide advice regarding professional negotiation.
I am willing to provide advice regarding professional negotiation.
yes
no
20
. I am willing to provide networking opportunities.
I am willing to provide networking opportunities.
yes
no
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