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Robert Wood Johnson Medical School Alumni Mentorship Survey
The purpose of this form is to create a database to improve mentoring and relationships between medical students and alumni. Please complete the form to identify your interests.
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Name
*
Your answer
Class Year
*
Your answer
Email
*
Your answer
Phone Number
Your answer
Specialty
*
Your answer
Current workplace
Your answer
Current title at workplace
Your answer
Current location of workplace
Your answer
Residency Program/Institution
Your answer
Would you be willing to
Connect with students interested in residencies or away rotations at your workplace
Have students shadow you
Involve students in research
Be featured in a RWJMS newsletter*
Speak at RWJMS events or lunch lectures
Connect with students in your city
Learn more about serving on the alumni board
Mentor undergraduate Rutgers students
Other:
Gender
Male
Female
Other:
Clear selection
To which racial or ethnic group(s) do you most identify?
Black/African-American (Non-Hispanic)
Asian/Pacific Islander
Caucasian (Non-Hispanic)
Hispanic or Latino
Native American or Aleut
Other/Multirace
Please describe yourself (check all that apply)
Underrepresented minority physician
LGBTQIA physician
Female physician in neurosurgery, orthopedics, urology, general surgery or radiology
Other:
Thank you!
Thank you for taking the time to fill out this form. We hope to use this database to increase mentoring opportunities and relationships with alumni and students. We appreciate all of your help!
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