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AMPP Mentorship Program Mentor Form
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* Indicates required question
Name
*
Your answer
Email
*
Your answer
Please indicate clinical practice specialty:
*
Outpatient Primary Care
Hospital Medicine
Outpatient and Inpatient General Practice
Specific Subspecialty (please specify in next question)
Other:
If you chose a specific subspecialty for previous question, please specify here:
Your answer
Clinical care patient population:
*
Internal Medicine (adults only)
Pediatrics
Both Internal Medicine and Pediatrics
Please indicate your practice setting:
*
Academic/University practice
Private (solo) practice
Private (group) practice
Health system practice
Federal (VA or FQHC) practice
Global/International Health
Other:
Please indicate past/present leadership experience(s):
*
Residency/Fellowship Program Leadership
Clinical practice leadership / Medical Director
Executive leadership
Dedicated Academic Leadership role (i.e. Dean/Associate Dean, Clerkship Director, Course Director, Chair/Vice Chair, Division Chief, DIO, Research/Center Director, Principal Investigator for Research Grant, Other)
Other:
Required
Please provide more detail regarding your past/present leadership experiences above, including whether they are based in IM, Peds, both, or neither.
*
Your answer
Please select up to 5 areas that you feel most comfortable as a source of mentorship or guidance:
*
Internal Medicine (adults only)
Pediatrics
Both Internal Medicine and Pediatrics
Academic/University practice
Private (solo) practice
Private (group) practice
Health system practice
Federal (VA or FQHC)
Global/International Health
Residency/Fellowship Program Leadership
Clinical practice leadership / Medical Director
Executive leadership
Dedicated Academic Leadership role (i.e. Dean/Associate Dean, Clerkship Director, Course Director, Chair/Vice Chair, Division Chief, DIO, Research/Center Director, Principal Investigator for Research Grant, Other)
Required
Please provide more detail regarding your choices in previous question if needed.
Your answer
Mentoring preferences - setting:
*
1:1
small groups
no preference
Mentoring preferences - availability (days):
*
weekdays
weekends
no preference
Mentoring preferences - availability (time):
*
daytime
evening
no preference
Mentoring preferences - number of mentees preferred:
*
1-2
3-5
>5
If you would like to have a brief bio on the mentoring website, please add this below (see example for reference). Max 150 words
Example biography:
Jane Trinh: I am currently division chief of the academic med-peds primary care group at Duke,
and am a professor of internal medicine and pediatrics. I had been in med-peds residency
program leadership for almost 15 years and have been in an academic environment since
finishing residency. I see adult primary care patients and precept med-peds residents in their
continuity clinic. I am currently involved in leadership training for residents, and I have just
started leading an adult primary care collaborative in our health system currently to promote
shared practices.
Your answer
Feel free to include a link to additional biographical information if listed on a health system, clinic, or academic site here:
Your answer
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