Exit this survey NASPAG Mentorship Program - Career Development Mentee Questionnaire Question Title * 1. Demographic information: Name: (Please put a forward slash / before and after / your typed name to constitute a lawful electronic signature.) Email Address: Question Title * 2. Specialty: Pediatrics Gynecology Internal Medicine Family Practice Nurse Practitioner Question Title * 3. Practice setting: Academic/Faculty Community Hospital Private Question Title * 4. Geographic location: State/Province: Country: Question Title * 5. Percentage of PAG in your practice: Question Title * 6. Surgical volume: Question Title * 7. Interest in research: Yes No Question Title * 8. Desire to host international member: Yes No Question Title * 9. Interest in academic advancement: Yes No Question Title * 10. Interest in research: Yes No Question Title * 11. List of faculty whom applicant would like as their mentor: (optional) Done