2020 Georgia CTSA TEAMS Program: Mentor Interest Form I. Mentor information Question Title * Name: Question Title * Email address: Question Title * Phone number (please provide the number that you can best be reached): Question Title * What is your Georgia CTSA affiliation? Emory University Georgia Institute of Technology Morehouse School of Medicine University of Georgia Other (please specify) Question Title * What is your academic discipline and/or department? (e.g., Psychiatry, Social Work, Biomedical Engineering, Pediatric Oncology) Question Title * What is your current academic position? Instructor Assistant Professor Associate Professor Professor Other (please specify) Question Title * How long have you been in your current position? Year(s): Month(s): Question Title * Current Time Allocation %If time allocation is 100% in one area, enter 0 in remaining sections. Clinical Research Teaching Administration Other (please describe) Question Title * How would you characterize your research? BasicAims to understand biological or natural processes. Clinical Defined as research with human subjects, including patient-oriented research, epidemiologic and behavioral studies, and outcomes research and health services research. TranslationalRefers to the process of turning observations in the laboratory, clinic, and community into interventions that improve the health of individuals and the public — from diagnostics and therapeutics to medical procedures and behavioral change. Other (please describe) Question Title * Mentoring experience: No previous mentoring experience Previous experience, but no current mentoring relationship Currently in mentoring relationship Please briefly describe your experience as a mentor (i.e., type & number of mentee(s), formal/informal, training, etc.) Question Title * Please provide a two sentence summary of your research so we may better match you with a fellow. Next