Leadership Program: Mentor Interest Survey

Mentorship Opportunity

NYSAFP is launching a Leadership Program for practicing physicians.

Would you consider mentoring a current practicing physician? Your leadership experience and commitment to NYSAFP would be an asset to the program.

Your participation will help us foster future Academy leaders. We encourage you to share your experience and insights.

Our goal is to increase participation and diversity in Academy leadership and provide additional professional support to Academy members.

Mentors will receive resources and potential discussion topics to support their mentoring activities and will be expected to commit to bi-monthly meetings (virtual or in-person).

If you are interested in this opportunity, please fill out survey below, thank you in advance for your consideration.

Questions? Please contact Jill Walls/jill@nysafp.org

Question Title

* 1. Please tell us a little bit about yourself

Prefix

First

Last

Suffix

Email Address (best address to reach you)

Phone Number (best number to reach you)

Question Title

* 2. How many years have you been in practice?

1-10

11-21

22+

Question Title

* 3. Please tell us a little bit about your worksite:

Organization Name

Main Worksite Address 1

Main Worksite Address 2

Main Worksite City

Main Worksite Zip

Question Title

* 4. In your practice of family medicine, do you have added training in any additional practice disciplines?

Addiction

Adolescent

Brain Injury

Clinical Informatics

Emergency Medical Services

Geriatric

Hospice and Palliative

Hospital

Maternal and Fetal Health

Pain

Sleep

Sports

Other practice discipline:

Question Title

* 5. How many providers are employed at your worksite?

1-4

5-20

Over 21

Additional comment:

Question Title

* 6. Please describe your current work setting (click all that apply):

Private (for profit, large- more than 50 employees)

Private (for profit, large- less than 50 employees)

Not for profit (large- more than 50 employees)

Not for profit (small- less than 50 employees)

Federally Qualified Health Center

Hospital

Accountable Care Organization (ACO)

Academic Institution

Self-employed (private practice)

Government (VA/armed forces)

Department of Health

Direct Primary Care

Rural

Health Professional Shortage Area (HPSA)

Medically Underserved Area (MUA)

Other (please specify)

Question Title

* 7. Please describe your past work settings that differ from your current one (click all that apply):

Private (for profit, large- more than 50 employees)

Private (for profit, large- less than 50 employees)

Not for profit (large- more than 50 employees)

Not for profit (small- less than 50 employees)

Federally Qualified Health Center

Hospital

Accountable Care Organization (ACO)

Academic Institution

Self-employed (private practice)

Government (VA/armed forces)

Department of Health

Direct Primary Care

Rural

Health Professional Shortage Area (HPSA)

Medically Underserved Area (MUA)

Other (please specify)

Question Title

* 8. Please identify any vulnerable, underserved or special needs individuals or communities that include members of minority populations or individuals who have experienced health disparities* that you treat (check all that apply):

*Per the Department of Health & Human Services

Latino populations

African American populations

American Indian/Alaska Native populations

Refugees

Individuals with limited English proficiency (LEP)

New mothers & women with children

Individuals with disabilities

Medicaid-eligible consumers who are not enrolled in coverage despite being eligible for Medicaid

Older adults

Rural populations

Children

Racial & ethnic minorities

People with physical or intellectual disabilities or cognitive, hearing, speech and/or vision impairments

Low income individuals

Homeless individuals

Pregnant people or post partum

Survivors of abuse or trauma

Individuals with mental health or substance-related disorders

Individuals with HIV/AIDS

Lesbian, gay, bi-sexual transgender, queer (LGBTQ) individuals

Young adults & post-secondary graduating students who do not have coverage options through a parent's plan, a student plan or an employer plan

Populations that receive fewer health care services

Populations that facing economic, cultural and/or linguistic barriers to accessing health care services

Populations with a lack of familiarity with the health care delivery system

Populations that live in locations where providers aren't readily available or physically accessible

Individuals who face significant hardships ( e.g., financial, educational, housing)

Other (please specify)

Question Title

* 9. If time/distance are not a factor, are you willing to meet with your mentee(s) in person?

Yes, I would like to meet in person

No, I would prefer the meetings to be conducted virtually

Additional Comments

Question Title

* 10. Do you consider yourself a part of a group that is underrepresented in medicine (check all that apply)?

Hispanic/Latino

Black/African American

Native Americans/Alaskans

Native Hawaiian/Pacific Islanders

Female

LGBTQ+

Other (please specify)

Question Title

* 11. Do you hold any other positions of leadership at your organization or with other medical academies (including NYSAFP)?

Yes

Yes, please list:

Question Title

* 12. Please elaborate on any additional skills or experiences you would bring to this program.

Question Title

* 13. Where did you hear about this program?

NYSAFP eNewsletter

NYSAFP email campaign

NYSAFP social media posts

Word of mouth

Other (please specify)

Leadership Program: Mentor Interest Survey

Mentorship Opportunity

Question Title

* 1. Please tell us a little bit about yourself

Question Title

* 2. How many years have you been in practice?

Question Title

* 3. Please tell us a little bit about your worksite:

Question Title

* 4. In your practice of family medicine, do you have added training in any additional practice disciplines?

Question Title

* 5. How many providers are employed at your worksite?

Question Title

* 6. Please describe your current work setting (click all that apply):

Question Title

* 7. Please describe your past work settings that differ from your current one (click all that apply):

Question Title

* 8. Please identify any vulnerable, underserved or special needs individuals or communities that include members of minority populations or individuals who have experienced health disparities* that you treat (check all that apply):*Per the Department of Health & Human Services

Question Title

* 9. If time/distance are not a factor, are you willing to meet with your mentee(s) in person?

Question Title

* 10. Do you consider yourself a part of a group that is underrepresented in medicine (check all that apply)?

Question Title

* 11. Do you hold any other positions of leadership at your organization or with other medical academies (including NYSAFP)?

Question Title

* 12. Please elaborate on any additional skills or experiences you would bring to this program.

Question Title

* 13. Where did you hear about this program?

* 8. Please identify any vulnerable, underserved or special needs individuals or communities that include members of minority populations or individuals who have experienced health disparities* that you treat (check all that apply):

*Per the Department of Health & Human Services