Mentorship Placement Survey

Thank you for your interest in volunteering for the American Academy of Optometry. This survey seeks to help properly place and match individuals for mentorship.

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* 1. I have reviewed the five mentorship training modules provided in the welcome letter.

Yes

Preliminary Information

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* 2. First Name

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* 3. Last Name

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* 4. State/Province

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* 5. Country

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* 6. Email Address

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* 7. Phone Number

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* 8. Demographics

American Indian or Alaskan Native

Asian or Pacific Islander

Black or African American

Hispanic

Inuit

Latinx

White/Caucasian

Prefer not to answer

Other (please specify)

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* 9. Gender

Male

Female

Non-binary

Prefer not to say

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* 10. Current Modes of Practice

Academic (research, clinical, administrator)

Corporate practice (franchise or owned by corporation)

Federal Service (military, VA, Indian Health Services)

Health Maintenance Organization

Industry/Exhibitor

Private practice with optometrists only

Private practice with various health care professionals

Retired

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* 11. Optometry School

Arizona College of Optometry, Midwestern University

Chicago College of Optometry

Illinois College of Optometry

Indiana University School of Optometry

Inter American University of Puerto Rico School of Optometry

Massachusetts College of Pharmacy and Health Sciences School of Optometry

Michigan College of Optometry at Ferris State University

New England College of Optometry

Northeastern State University - Oklahoma College of Optometry

Nova Southeastern University College of Optometry

Pacific University College of Optometry

Pennsylvania College of Optometry at Salus University

State University of New York College of Optometry

Southern California College of Optometry at Marshall B. Ketchum University

Southern College of Optometry

The Ohio State University College of Optometry

University of Alabama at Birmingham School of Optometry

University of California Berkeley School of Optometry

University of Houston College of Optometry

University of the Incarnate Word Rosenberg School of Optometry

University of Missouri at St. Louis

University of Montreal School of Optometry

University of Pikeville Kentucky College of Optometry

University of Waterloo School of Optometry and Vision Science

Western University of Health Sciences College of Optometry

Other (please specify)

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* 12. OD Graduation Year

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* 13. Years in Practice

Less than 5 years

5 - 10 years

11 - 20 years

21 - 30 years

More than 30 years