WMG Mentorship Program - MENTOR SIGN UP

Question Title

1. Contact Information

Name

Institution

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

2. Academic Rank

Question Title

3. Where did you do your Fellowship Training?

Question Title

4. Where did you do your residency and what year?

Question Title

5. Which career track best describes you?

Academic/University

Private Practice

Hospital-based/Employed

Question Title

6. Which practice mix best describes you?

100% reconstructive

Reconstructive with some cosmetic

50/50 reconstructive/cosmetic

Mainly cosmetic with some reconstructive

Question Title

7. What is your career blend?

100% Clinical

80%/20% Clinical/Research

60%/40% Clinical/Research

20%/80% Clinical/Research

100% Research

Question Title

8. What types of cases do you perform? (select all that apply)

Breast reconstruction

Upper extremity reconstruction

Lower extremity reconstruction

Lymphedema surgery

Gender surgery

Head and neck reconstruction

Nerve surgery

Question Title

9. Select all that apply so we can best match you

single

married

young family

no family now, but want

partner in medicine

same-sex partner

Question Title

10. Number of Mentees you are willing to have

Question Title

11. Preferred level of training of mentee:

Medical Student

Resident

Fellow

Junior Faculty