NASPAG Mentorship Program - Career Development Mentor

Mentor Questionnaire

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* 1. Demographic information:

Name: *

Institution

City/Town:

State/Province:

Country:

Email Address: *

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* 2. Specialty:

Pediatrics

Gynecology

Internal Medicine

Family Practice

Nurse Practitioner

Other (please specify)

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* 3. Practice setting:

Academic/Faculty

Community

Hospital

Private

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* 4. Percentage of PAG in your practice:

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* 5. Surgical volume:

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* 6. Interest in research:

Yes

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* 7. Desire to host international member:

Yes

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* 8. Number of mentees:

One

Two

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* 1. Demographic information:

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* 2. Specialty:

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* 3. Practice setting:

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* 4. Percentage of PAG in your practice:

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* 5. Surgical volume:

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* 6. Interest in research:

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* 7. Desire to host international member:

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* 8. Number of mentees:

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* 9. Please explain what goals you would like to achieve with your mentee: