IHPBA Mentor Form

IHPBA Mentor Form
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*

YesNo
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 *

Cancelof
Mentorship Details
15. Are you willing to host fellows at your institution*

YesNo
16. Specific support areas you can provide (please select all that apply)*

Clinical GuidanceResearch MentorshipCareer DevelopmentOther
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*

YesNo
20. I agree to my contact details being included on the Kenneth Warren Fellowship mentor list on the IHPBA website*

YesNo
21. I agree to the IHPBA management office contacting me by email if required*

YesNo
Should be Empty:

IHPBA Mentor Form

Personal Details

Professional Background

Mentorship Details

Past Mentorship Experience