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Pediatric Diversity, Equity & Inclusion Catalyst Interest Form 2020-21
Please fill out this form if you are interested in being a Pediatric Diversity, Equity & Inclusion Catalyst.

Catalysts who are selected will be asked to participate in a series of DEI faculty development trainings and participate in regular meetings to foster a community of practice. The faculty development trainings are often held during work hours; there are about 5 trainings we will ask you to attend over the academic year. We are considering holding the regular community of practice meetings via zoom in the evenings, but will finalize a plan once we have a cohort.

Filling out this application is an indication of interest (not a commitment!); we will get back to you with more information.

 Email jyothi.marbin@ucsf.edu with any questions. Thank you!!
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Name *
Why are you interested in being a Pediatric Diversity, Equity & Inclusion Catalyst?
Where do you spend most of your time clinically?
Clear selection
Have you completed the Differences Matter Champions Training?
Clear selection
What other DEI related trainings have you completed in the past 3 years?
Are you able to commit 4-6 hours/month to this role?
Clear selection
Is your manager supportive of you taking on this role?
Clear selection
What are some ways in which you think the pediatric learning climate at your site could be more inclusive?
Is there anything else you would like to share?
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