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NASPAG Mentorship Program - Research

Mentee Questionnaire

Question Title

* 1. Demographic information:

Name: *

Institution:

City/Town:

State/Province:

Country:

Email Address: *

Phone Number:

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* 2. Professional level:

Resident

Fellow

Faculty

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* 3. Professional specialty:

Obstetrics/Gynecology

Pediatrics

Other (please specify)

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* 4. Years of research experience:

0 - 1

1 - 5

>5

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* 5. Areas of research interest:

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* 6. Focus of support from mentor: (mark all that apply)

Research idea generation

Grantsmanship

Manuscript review

Abstract preparation

Other (please specify)

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* 7. List of faculty whom applicant would like as their mentor: (optional)