* 1. Name:

* 2. Title:

* 3. Institutional Affiliation:

* 4. Email:

* 5. Telephone Number:

* 6. Do you envision participating in this program as a...

* 7. Please provide the following information about your current global health educational program:

* 8. Which of the following problems or concerns would you like to address as part of this advisory service? (Please indicate ALL that apply)

* 9. For advisees, please provide a brief description of the most important issues you wish to address in the coming year. (Include up to 3 areas you wish to work on and indicate in descending order the most to least important.)

* 10. For advisees, if you are to use the CUGH advisory service, please describe what 'success' will look like for you.

* 11. For mentors, please indicate which of the following areas you feel most comfortable in providing assistance. (Please indicate all that apply.)

* 12. For mentors, if you participate in the CUGH advisory service, what would a successful mentor-advisee relationship look like to you?

* 13. For mentors, the minimum expected commitment includes regular telephone communication (preferable a monthly call), a site visit and a final report of recommendations. Do you feel you are able to provide this level of commitment?

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