AEMP Mentor Survey 2026
Please fill out the survey below if you are interested in participating in the mentor-mentee program this year!
Name
*
First Name
Last Name
Credentials
*
Preferred Email
*
example@example.com
Professional Photo For Website (Optional)
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of
Current Practice Site
Trauma Care Designation
Level I
Level II
Level III
Level IV
Level V
Pediatric Trauma Center
Not a Trauma Center
Type of ED Population
Adults
Pediatrics
Education/Work Experience
College of Pharmacy
*
Non-Pharmacy Degrees
Post-Graduate Pharmacy Training
*
PGY1
PGY2
Fellowship
None
Additional Training and/or Certificates
PGY1 Program
PGY2 Type/Program
Fellowship Type/Program
Total Years of Pharmacist Experience (including Residency Training)
*
Total Years of ED Experience
*
Involvement and Experience in Current Position
Please describe your involvement in the following areas of your practice:
Maintenance work (e.g. committee work, protocol/order set development, formulary management)
Initiatives (e.g. quality Improvement, new services, novel practice areas, interdisciplinary education opportunities)
Things outside of my job description (e.g. organization involvement and professional development)
Precepting & Teaching Experience
Faculty Position or Academia Involvement
Yes
No
Type of College Involvement: (Pharmacy vs. other Healthcare Colleges)
Faculty Designation:
Classes Taught
Precepting Experience (select all that apply):
Students
PGY1
PGY2
No precepting experience
RPD Experience (past or current)
Yes
No
RPD Program
Years as RPD
Research Experience
Link to Google Scholar or ORCID ID
Research Experience
Yes
No
Please include MUE/QA Projects that wouldn't be captured by the previous question.
Are you open to collaboration on research?
Yes
No
What facets of research are you willing to precept or assist with?
Are there any areas not covered or highlighted above you would want to share with interested mentees?
Please share a fun fact about yourself (could include hobbies, places you've traveled, etc.).
Select the type of mentee you would be willing to provide mentorship for (select all that apply):
*
Student
PGY1
PGY2
Pharmacist
Physician or other EM Provider
Please indicate the number of mentees you would be willing to take during a yearly period? (We will confirm this interest on a yearly basis.)
*
1
2
3
As many that need assistance
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