This form is designed to collect information that will allow us to best pair you with another academic mother with similar goals and interests. Your personal information will only be used to pair you with a colleague and will NEVER be shared with anyone else or used for marketing reasons. There are 16 questions in the form. Please complete at least the questions with an asterisk, to help us to find you the best match. Feel free to also use the last question to offer any feedback for improving this form, including adding new questions or answers. Thank you for taking the time!
CONTACT INFORMATION

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* 1. Please write the exact word that follows in the textbox: Hi

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* 2. First name

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* 3. Last name

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* 4. Email

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* 5. Phone Number (this is only for sharing with your paired colleague)

TELL US ABOUT THE WORK OR PROJECT YOU HOPE TO RECEIVE SUPPORT ON.

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* 6. Projects you are currently working on or hope to develop (please select all that apply)

THE FOLLOWING QUESTIONS ASK ABOUT YOUR CRITERIA OR PREFERENCES FOR PAIRING WITH A COLLEAGUE

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* 7.
Do you wish to be paired specifically with someone from your academic discipline? (If you wish to be paired with someone in your discipline, please write down your discipline and/or your sub-discipline in the next question)

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* 8. Discipline or sub-discipline

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* 9. Do you wish to be be paired with someone at the same rank or role as yourself? (if yes, please indicate your role or rank in the section on mentoring)

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* 10. Please share additional personal or professional criteria that you may want to have in common with your paired colleague. Feel free to also recommend additional pairing criteria in the last feedback question

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* 11. Pairing: How often would you like to be in touch with someone you are paired with?

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* 12. I envision or hope that working with another academic mother will include which of the following. (please feel free to add additional suggestions for this question in the last question)

MENTORING OF STUDENTS OR JUNIOR COLLEAGUES.

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* 13. If you are a faculty member, are you open to mentoring a student or junior colleague?

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* 14. What is your current role? (please respond to this question if you are a student or junior colleague, or if you wish to be a mentor)

OTHER POSSIBILITIES FOR PROFESS*HER.

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* 15. If offered, would you subscribe to receive occasional text messages for support, encouragement, and announcements for online events or activities related to women in academia?

FEEDBACK. 

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* 16. Please use this space to share additional questions for this survey, as well as ideas for tools or resources to support you and other academic mothers, or other feedback.

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