Thanks for you interest in serving as a Mentor
in NEDS Resident Preceptorship Program

Please fill in your information below.

Question Title

* 1. Anticipated setting of your mentorship

teaching hospital

non-teaching hospital

private practice

No physical setting (remote format)

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* 2. Anticipated mentorship location:

City/Town

State

No physical location (enter "REMOTE")

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* 3. Mentor's affiliation details:

Affiliated Hospital or Private Practice Name

Affiliated Department if applicable

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* 4. Please identify up to 3 potential areas of mentorship/expertise to be offered to interested residents:

Area 1:

Area 2:

Area 3:

Question Title

* 5. (optional) Additional details regarding area 1

Question Title

* 6. (optional) Additional details regarding area 2 (if applicable)

Question Title

* 7. (optional) Additional details regarding area 3 (if applicable)

Question Title

* 8. Your contact information to be used by the Preceptorship Program:

Name

Address

City/Town

State/Province

Email Address

Phone Number

Thank you for your interest! Your information will be reviewed by the Preceptorship Subcommittee. You will be contacted to confirm more details if needed. Otherwise, the information you provided will be shared with resident applicants who request it.

Thanks for you interest in serving as a Mentor in NEDS Resident Preceptorship Program

Question Title

* 1. Anticipated setting of your mentorship

Question Title

* 2. Anticipated mentorship location:

Question Title

* 3. Mentor's affiliation details:

Question Title

* 4. Please identify up to 3 potential areas of mentorship/expertise to be offered to interested residents:

Question Title

* 5. (optional) Additional details regarding area 1

Question Title

* 6. (optional) Additional details regarding area 2 (if applicable)

Question Title

* 7. (optional) Additional details regarding area 3 (if applicable)

Question Title

* 8. Your contact information to be used by the Preceptorship Program:

Thanks for you interest in serving as a Mentor
in NEDS Resident Preceptorship Program