2022 RBMA Leadership Mentoring Program - Mentee Application

Thank you for your interest in RBMA's Leadership Mentor Program. To be considered, please fill out the application below as thoroughly as possible. The application is due August 3, 2022

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* 1. Full Name:

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* 2. Organization

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* 3. Current Position:

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* 4. Email:

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* 5. Phone (Best number to reach you):

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* 6. Please select your time zone

Central (CT)

Eastern (ET)

Mountain (MT)

Pacific (PT)

Other (please specify)

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* 7. Share a short summary (30-50 words) of the work you perform at your organization:

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* 8. Your educational background [include both formal (degrees) and informal (certificates, proficiencies)]:

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* 9. What interests you in becoming a mentee?

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* 10. What challenges would you like to resolve with your mentor?

Challenge 1

Challenge 2

Challenge 3

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* 11. What are the three ideal characteristics of your mentor?

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* 12. Specific areas of information that would be of most value to you:

Career guidance

Technical expertise in my field

Radiology culture, structure and relations

Leadership skills

Direction on taking the next step in my career

Managing a team

Increasing my financial/budget acumen

Other (describe)

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* 13. Select your generation:

Boomer [1946-64]

Gen Xers [1965-1980]

Millennials [1980-1995]

Gen Z (1996-2012)

Other (please specify)

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* 14. What is your race?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 15. Please select your age range

25-34

35-44

45-54

55-64

65+

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* 16. Select your career stage

New CEO/Practice Leader

Early career, 1-5 years

Mid-Level Manager/Director, 6-10 years

Senior: 11 or more years

Other (please specify)

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* 17. What is the ideal frequency of mentor/mentee check-in?

Twice a month

Monthly

Every other month

Quarterly

Other (please specify)

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* 18. To avoid pairing you with an individual who is your organization's competitor. Please list the top competitors for you and/or your organization.

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* 19. To match you with a mentor that aligns with your professional and personal goals, please describe the professional strengths and areas for which you seek guidance and mentorship.

2022 RBMA Leadership Mentoring Program - Mentee Application

Question Title

* 1. Full Name:

Question Title

* 2. Organization

Question Title

* 3. Current Position:

Question Title

* 4. Email:

Question Title

* 5. Phone (Best number to reach you):

Question Title

* 6. Please select your time zone

Question Title

* 7. Share a short summary (30-50 words) of the work you perform at your organization:

Question Title

* 8. Your educational background [include both formal (degrees) and informal (certificates, proficiencies)]:

Question Title

* 9. What interests you in becoming a mentee?

Question Title

* 10. What challenges would you like to resolve with your mentor?

Question Title

* 11. What are the three ideal characteristics of your mentor?

Question Title

* 12. Specific areas of information that would be of most value to you:

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* 13. Select your generation:

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* 14. What is your race?

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* 15. Please select your age range

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* 16. Select your career stage

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* 17. What is the ideal frequency of mentor/mentee check-in?

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* 18. To avoid pairing you with an individual who is your organization's competitor. Please list the top competitors for you and/or your organization.

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* 19. To match you with a mentor that aligns with your professional and personal goals, please describe the professional strengths and areas for which you seek guidance and mentorship.

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* 20. Where do you see yourself 5-10 years from now?