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ILMA-USA mentorship questionnaire for mentees
ILMA USA
ILMA-USA mentorship questionnaire for mentees
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Please complete this form to the best of your ability to help connect you with a suitable mentor
Email
*
Please enter a valid email address
Full name
*
Your answer
Preferred email address
*
Your answer
Nationality
*
Algeria
Argentina
Australia
Austria
Bahrain
Bangladesh
Belgium
Brazil
Canada
Chile
China
Colombia
Egypt
Ethiopia
France
Germany
Greece
India
Indonesia
Iran
Iraq
Ireland
Italy
Japan
Jordan
Kenya
Kuwait
Lebanon
Malaysia
Mexico
Morocco
Netherlands
New Zealand
Nigeria
Norway
Oman
Pakistan
Palestine
Peru
Philippines
Poland
Portugal
Qatar
Russia
Saudi Arabia
South Africa
South Korea
Spain
Sweden
Switzerland
Syria
Thailand
Tunisia
Turkey
Ukraine
United Arab Emirates
United Kingdom
United States
Vietnam
Yemen
Do you hold a second nationality?
*
Yes
No
If yes, please specify your second nationality:
Location (City, Country)
*
Your answer
Medical school name:
*
Highest degree (e.g., M.D., B.S., Ph.D.)
*
Current level of education (e.g., medical student, post-doc, fellow, undergraduate)
*
Specialty, if applicable
Current training institution
Have you had prior mentors?
Yes
No
Do you have current mentors?
Yes
No
Please specify the name and affiliation of your current mentor(s)
Your answer
What do you want to achieve from the mentorship program?
Basic Research (e.g.,designing a study, developing skills, data analysis)
Clinical research (e.g., patient recruitment, study design, funding)
Career development- transitioning from training to staff or faculty, areas of interest, and specialty choice and preparedness
Training advice (e.g., navigating residency and applications)
Writing skills (e.g., grants, manuscripts, abstracts, personal statement, communication)
Personal development (e.g., leadership/negotiation,CV)
Please choose the career development focus
Academic
Hospital-based
Private solo
Private group
Global health/Advocacy
Please estimate the required time to achieve your mentorship goals
1-3 months
4-6 months
7-9 months
10-12 months
Not sure
How frequently would you need to meet with the mentor to reach your goals?
Weekly
Every 2 weeks
Every 3 weeks
Every 4 weeks
Not sure
How did you hear about the mentorship program?
Social media
Word of mouth
Email communication
What is your preferred mode of communication?
In-person, face-to-face (only in the USA)
Telephone
E-mail
Virtual meeting
Biographic questions (Briefly explain your career goals - frame it with 5-10 year goals Limit 1000 characters)
*
What do you expect from the mentorship program? Limit 1000 characters
*
Submit
