MAOFP Mentor Program

Thank you for your interest in the MAOFP Mentor Program. Complete the following form to indicate your interest in participating in the program.

The goal of the program is to facilitate meaningful one-on-one mentorship opportunities where experienced physicians share expertise and guidance with students, residents, and new physicians.

MAOFP will hold a virtual kick-off meeting on April 13, 2021 from 7-8 PM to review the program structure and expectations of participation. Each mentorship pair will determine their own schedule and methods of communication (scheduled calls, in-person or virtual meetings, emails, etc.). It is highly recommended that each pair connect at least once per month.

Question Title

* 1. Please provide your contact information.

Name:

Degree / designation:

City:

Email address:

Phone number:

Question Title

* 2. Please indicate your current status.

Physician in practice for more than 5 years

Physician in practice for less than 5 years

Retired physician

Resident

Student

Question Title

* 3. Do you wish to be a mentor or mentee?

Mentor

Mentee

Both

Question Title

* 4. Medical school graduation and date:

Question Title

* 5. Residency program and graduation date:

Question Title

* 6. What is your current or desired future family medicine practice setting? (Select all that apply.)

Solo practice

Group practice

Hospital

Academic

Other (please specify)

Question Title

* 7. Please indicate your current or future interests/expertise. (Select all that apply.)

Education

Emergency and urgent care

Hospitalist / inpatient medicine

Maternity care / obstetrics

Pediatrics

Procedures

Public health

Research

Sports medicine

Women’s health

Other (please specify)

Question Title

* 8. Briefly share any areas of needed support from a mentor and/or knowledge and guidance that can be shared with a mentee.

Question Title

* 9. I agree to comply with the following expectations of MAOFP’s Mentor Program.

Adhere to the communications schedule established by the mentorship pair and/or provide timely notice when rescheduling is necessary.

Come prepared for each communication and follow through on agreed-upon action steps (e.g., sharing a resource, making an introduction).

Respond to calls/emails from the mentor/mentee in a timely manner.

Respect the confidentiality of discussions and only disclose information discussed with the permission of the mentor/mentee.

Notify MAOFP staff immediately if you are no longer able to actively participate in the program.

Yes