Exit Research Mentorship Database Question Title * 1. Contact Info Name: Practice Institution: Email: Best Phone Contact #: Question Title * 2. Years after fellowship graduation <5 years 5-10 years 10-15 years >15 years Question Title * 3. Academic Title/Private Practice Instructor Assistant Professor Associate Professor Professor Private Practice Physician Question Title * 4. Research interest Clinical research Basic research Translational research Clinical trials Question Title * 5. Interested research area Question Title * 6. Representative publications (please list 2-5 publications) Question Title * 7. Are you willing to serve in the mentorship program? Yes No Question Title * 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 Question Title * 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 Done >>
