IHPBA Mentor Directory

IHPBA Mentor Directory
Personal Details
1. Name

Prefix (Dr, Prof, Mr, Ms, Mrs, Mx, Other) First NameFamily Name
2. Email
example@example.com
3. Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
4. Phone Number

Area CodePhone Number
5. Gender
Collecting gender identity data can help us identify gaps and develop resources to address disparities.
If not listed please describe your gender
6. Date of Birth

MonthDayYear
Date
7. Describe your ethnicity
Collecting data on ethnicity can help us identify gaps and develop resources to address disparities.
Ethnicity Other/Prefer to self describe
8. Region
9. Are you a member of a National Chapter
Please select your National Chapter
Professional Background
10. Current Job Title
11. Institution/Organization
12. Area of expertise in HPB Surgery
13. Years of experience
14. Please upload your CV/resume or a short outline of your qualifications and work experience

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Mentorship Details
15. Are you willing to host fellows at your institution
16. Specific support areas you can provide (please select all that apply)

Other
17. Availability for mentorship (e.g. hours per month):
Number of hours per month
Past Mentorship Experience
18. Describe any previous experience mentoring trainees or fellows
19. Have you had any formal mentorship training
20. I agree to my contact details being included on the Kenneth Warren Fellowship mentor list on the IHPBA website
21. I agree to the IHPBA management office contacting me by email if required
Should be Empty:

IHPBA Mentor Directory

Personal Details

Professional Background

Mentorship Details

Past Mentorship Experience