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* 1. What is your full name?

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* 2. What is your primary email address?

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* 3. What is your level of medical training?

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* 4. What hospital or institution are you affiliated with?

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* 5. What city and state do you live in most of the time?

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* 6. If you are a medical student, what is your year in training?

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* 7. If you are a resident, what is your year in training?

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* 8. What is your specialty? (N/A if medical student)

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* 9. Do you anticipate being able to dedicate 1 hour per week, plus occasional emails/texts/etc., interfacing with your Mentee?
(curriculum, mentorship training, and software provided)

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* 10. Do you have experience mentoring or educating premedical students?

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* 11. Are you a returning PrIMES Mentor?

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* 12. Were you a PrIMES Mentee in the past?

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* 13. What skills, knowledge, or experiences do you have that would make you a successful and effective Mentor for PrIMES Mentees?

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