1.First Name:

2.Last Name:

3.Please indicate your institute.

CCCITCSRFICNCATSNCCIHNCINEINHLBINHGRINIANIAAANIAIDNIAMSNIBIBNICHDNIDCDNIDCRNIDDKNIDANIEHSNIGMSNIMHNIMHDNINDSNINRNLM

4.Staff Clinician Title:

Assistant Research PhysicianAssociate Research PhysicianSenior Research PhysicianNo Research Physician TitleUnsure of Title

5.Years in Staff Clinician Position at NIH:

Less than 2 years

2-4 years

5-6+ years

6.Are you able to commit to attending three one-hour in-person professional development sessions and one daylong session on coaching in academic medical careers?
These sessions are tentatively scheduled as follows:
- Session 1: NIH Staff Clinician Faculty Mentoring Program Introduction (1-hour session in May 2026)
- Session 2: Staff Clinician/Research Physician Titles (1-hour session in June 2026)
- Session 3: Staff Clinician Career Development Plans (1-hour session in September 2026)
- Session 4: Coaching Your Career (One full-day session, October 2026)

Yes

No

Maybe

7.Describe Your Career Vision (100-200 words):
How do you see your career evolving over the next 5-10 years? What achievements and/or contributions would you like to make as an NIH Clinical Faculty member?

8.Briefly describe your mentoring needs (100-200 words):
Which specific areas (e.g., clinical skills, research, medical education and training, leadership) would you like to receive mentorship in? Please describe any gaps in your knowledge or experience that you believe need to be addressed in order to achieve your career vision. If you seek mentorship in multiple areas, feel free to list them, but indicate which one is most important to you and explain why.