MSD Mentorship Participation Survey

You are invited to participate in MSD's Mentorship Program

Participating as a mentor, a mentee (or both) allows you the opportunities to establish and cultivate relationships that match your desired level of participation. Connecting one-on-one, providing/receiving support and guidance and engaging with medical professionals will benefit you at all times of your medical career.

Please take a few minutes to complete this brief survey so we can enroll you in the program and get started.

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* I am interested in being:

Mentor

Mentee

Both

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* I am interested in being a part of the MSD Mentorship Work Group to help plan activities, match mentors with mentees and provide support to this program

Yes

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* Name

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* Medical Specialty

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* Please choose the appropriate status

Medical Student

Resident/Fellow

Physician (actively practicing)

Physician (retired, emeritus)

Other (please specify)

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* Graduation/training dates

medical school graduation year

residency/fellowship completion year

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* Location of practice/training

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* Scope of Practice/Area of Practice

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* Preferred method(s) of communication (check all that apply)

Text

Phone Call

In-Person

Other (please specify)

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* Preferred interval of communication

weekly

monthly

quarterly

yearly

as scheduled basis

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* Hometown

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* If participating as a MENTEE, what areas would you like to focus on during this mentorship? (Select up to 3)

Navigating residency or fellowship/navigating the early years of starting practice after training

Research guidance

Career planning (e.g., fellowship, private practice, academia)

Leadership development

Wellness and work-life balance

Time management/productivity

Networking and professional relationships

Advocacy and community engagement

Other (please specify)

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* If participating as a MENTEE, which is your preferred mentor background?

Same specialty

Different specialty

No preference

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* If participating as a MENTOR, what categories of mentorship can you offer? (Select all that apply)

Navigating residency or fellowship/navigating the early years of starting practice after training

Research guidance

Career planning (e.g., fellowship, private practice, academia)

Leadership development

Wellness and work-life balance

Time management/productivity

Networking and professional relationships

Advocacy and community engagement

Other (please specify)

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* If participating as a MENTOR, How many mentees can you take on? (1, 2, or 3)?

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* If participating as a MENTOR, do you prefer mentees in your specialty/department or open to all?

prefer same specialty/department

open to all specialties/department (no preference)

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* If participating as a MENTOR, is there anything else you'd like the mentorship workgroup to consider when assigning mentees?

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* Professional/Medical interests (top 3)

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* Personal Interests (top 3)

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* Please provide your contact information so we may contact you regarding next steps.

Email Address

Phone Number