LIJ Medical Staff Society
Women in Medicine Mentorship Program Mentor/Mentee Questionnaire
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Number
*
Email
*
example@example.com
Professional Title:
*
Years in Practice:
Employment Status (FT, PT, Private):
Please select which role you are interested in:
Please Select
Mentor
Mentee
1. In your opinion, what makes a mentor/mentee valuable to you?
2. What skills or knowledge do you hope to acquire from a mentor? Or, what do you hope to contribute or acquire from your mentee?
3. Do you prefer a mentor/mentee in your own area of professional expertise? (Medicine, Academics, Administration, Faculty or Private Practice) If not, which area do you prefer?
4. What are your short and long term goals? Where do you see yourself in 5 years and in 10 years?
5. What day, time and location do you prefer to meet with your mentor/mentee (can be in person, email, phone/skype)
Submit
Should be Empty: