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Research Mentorship Database
*
1.
Contact Info
(Required.)
Name:
Practice Institution:
Email:
Best Phone Contact #:
*
2.
Years after fellowship graduation
(Required.)
<5 years
5-10 years
10-15 years
>15 years
3.
Academic Title/Private Practice
Instructor
Assistant Professor
Associate Professor
Professor
Private Practice Physician
4.
Research interest
Clinical research
Basic research
Translational research
Clinical trials
*
5.
Interested research area
(Required.)
*
6.
Representative publications (please list 2-5 publications)
(Required.)
7.
Are you willing to serve in the mentorship program?
Yes
No
8.
If yes to question 8, how often do you think mentorship program should meet?
twice a month
once every month
once every two months
9.
Do you give ASDIN consent to post your contact info and prior research information on ASDIN website as part of an online Research Resource Database? (In addition to matching mentors and trainees, we would like to create a research resource database on the ASDIN website)
Yes
No
