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Program Coordinator Mentor Request
The information provided on this form will be used by the Coordinator Advisory Work Group Coordinator Engagement Sub-Committee to match you with a mentor. Please note that while your mentor may not have expertise in every area you list, the sub-committee will do it's best to find additional resources to meet your needs.
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Please provide the following information about yourself and your work:
Your name: *
Your department/division: *
Your program(s) indicating if residency or fellowship: *
Please provide your email address and phone number, and indicate your preference for communication: *
Is one or more of your programs NOT ACGME accredited? *
How long have you been in your current role?
Please list any specific areas of your role for which you would like guidance and support. The more specific the better!
Of the areas you are seeking guidance in, which are your top priorities?
Pleas provide the name/names of the person/people providing your training within the department/program.
Is there any additional information you'd like to share that might help the committee pair you with a mentor?
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