SHM Converge 2024 Speed Mentor Recruitment

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* 1. Name

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* 2. Contact Email

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* 3. I identify my gender as:

Female

Male

Transgender Female

Transgender Male

Gender Non-Binary/Gender-fluid/Agender

Prefer not to disclose

My identity is not listed

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* 4. Describe your racial or ethnic background (Select all that apply):

American Indian or Alaska Native

Asian/East Asian/Asian American

Black or African American

Hispanic or Latino

Middle Eastern

Native Hawaiian or Other Pacific Islander

South Asian

White

Multiracial

Prefer not to disclose

Other (please specify)

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* 5. My practice setting (Select all that apply):

Community-based

Community-based university affiliate

University-based

Military

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* 6. Years in practice:

<5 years

5-10 years

11-15 years

>15 years

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* 7. Domains of expertise (Select all that apply)

Quality Improvement/Patient Safety

Hospital Leadership

Medical Education

Informatics

Global Health

Research

Scholarship (e.g. meeting abstracts or workshops, case reports)

Interprofessional Education

Diversity, Equity, and Inclusion

Other (please specify)

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* 8. Are you open to mentoring NP/PAs?

Yes

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* 9. Have you participated in this event before as a mentor or mentee (select all that apply)?

Mentor

Mentee

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* 10. Institution

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* 11. Please upload your CV here. Please format the file name to be 'LAST NAME_SHM Mentor'

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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SHM Converge 2024 Speed Mentor Recruitment

Question Title

* 1. Name

Question Title

* 2. Contact Email

Question Title

* 3. I identify my gender as:

Question Title

* 4. Describe your racial or ethnic background (Select all that apply):

Question Title

* 5. My practice setting (Select all that apply):

Question Title

* 6. Years in practice:

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* 7. Domains of expertise (Select all that apply)

Question Title

* 8. Are you open to mentoring NP/PAs?

Question Title

* 9. Have you participated in this event before as a mentor or mentee (select all that apply)?

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* 10. Institution

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* 11. Please upload your CV here. Please format the file name to be 'LAST NAME_SHM Mentor'

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* 12. Given your career experience and expertise, please provide 2 examples of mentorship advice you might provide to a mentee in Speed Mentoring.