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Thanks for you interest in serving as a Mentor
in NEDS Resident Preceptorship Program
Please fill in your information below.
OK
1.
Anticipated setting of your mentorship
teaching hospital
non-teaching hospital
private practice
No physical setting (remote format)
2.
Anticipated mentorship location:
City/Town
State
No physical location (enter "REMOTE")
3.
Mentor's affiliation details:
Affiliated Hospital or Private Practice Name
Affiliated Department if applicable
*
4.
Please identify up to 3 potential areas of mentorship/expertise to be offered to interested residents:
(Required.)
Area 1:
Area 2:
Area 3:
5.
(optional) Additional details regarding area 1
6.
(optional) Additional details regarding area 2 (if applicable)
7.
(optional) Additional details regarding area 3 (if applicable)
8.
Your contact information to be used by the Preceptorship Program:
Name
Address
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
Email Address
Phone Number
Thank you for your interest! Your information will be reviewed and you will be contacted if further details are needed. Otherwise, the information you provided will be shared with resident applicants who request it.
Current Progress,
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