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2022 Call for Mentors - Research Track
If interested in the Leadership Track, please
apply here
. This application is the Call for Mentors - Research Track only.
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1.
Contact Information
(Required.)
Name
Academic Institution
Job Title
Email Address
Phone Number
*
2.
What are your areas of strength that mentees could find beneficial?
(Required.)
Grant writing
Identifying sources of funding
Finding collaborators
Budget preparation
Post award management
Manuscript writing/submission
Identifying eligibility for grants
Other (please specify)
*
3.
Primary Health Profession
(Required.)
Anesthesiology
Athletic Training
Audiology
Biomedical Sciences
Biostatistics
Cardiovascular Perfusion Technology
Clinical Laboratory - Medical Technology and Medical Laboratory Technology
Cytotechnology
Dental Hygiene
Diagnostic Medical Sonography
Dietetics/Nutrition
Emergency Medical Sciences
Exercise Sciences
Genetic Counseling
Gerontology
Health Administration
Health Information Management
Health Sciences/Allied Health Sciences
Kinesiology
Magnetic Resonance Imaging
Medical Assisting
Nuclear Medicine Technology
Nurse Anesthesia
Nursing
Occupational Therapy
Orthodics and Prothetics
Pharmacy Assisting
Physical Therapy
Physician Assistants
Psychology
Public Health
Radiation Technology Therapy
Radiology
Rehabilitation Counseling
Respiratory Therapy
Social Work
Speech-Language Therapy
Surgical Technology
Other (please specify)
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4.
Highest Earned Academic Degree
(Required.)
PhD
MPH
DrPH
MHA
EdD
DSc
MD
MS
MBA
JD
Other (please specify)
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5.
Current academic rank
(Required.)
Instructor
Assistant Professor
Associate Professor
Professor
Other (please specify)
*
6.
Are you tenured?
(Required.)
Yes
No
Other (please specify)
*
7.
Are you tenure-eligible?
(Required.)
Yes
No
Other (please specify)
*
8.
Appointment term
(Required.)
12 month
9/10 month
Other (please specify)
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9.
Do you have an administrative/leadership role?
(Required.)
Yes
No
If yes, please list (e.g. Dean, Associate Dean...)
*
10.
In key word format, what are your areas of active research?
(Required.)
Area 1
Area 2
Area 3
Area 4
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11.
Do you currently have extramural funding?
(Required.)
Yes
No
12.
If yes to question 11, you may list up to 3 funding agencies with the info below.
Title of project:
Total amount of funding:
Investigative role: PI/co-PI/Investigator
Funding Period:
*
13.
Do you currently have intramural funding?
(Required.)
Yes
No
14.
If yes to question 13, you may list up to 3 funding agencies with the info below.
Title of project:
Total amount of funding:
Investigative role: PI/co-PI/Investigator
Funding Period:
*
15.
Are you willing to peer review grant submissions?
(Required.)
Yes
No
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16.
Do you have any best practices to share in promoting high level of research productivity among research faculty?
(Required.)
Yes (a Research Committee Member may reach out for additional details)
No
Other (please specify)
17.
Additional Comments/Questions
