MENTOR PROGRAM INTEREST FORM
Please answer the below questions to show your interest in a mentor program. Questions with an asterisk require an answer.
Name
Title
Organization
*
Email Address (will only to be used to follow-up regarding mentor program involvement)
*
Worksite (select the best fit)
Academic Education Institution
Academic Medical Center
Ancillary Clinical Service Provider
Banks/Financial Services
Community Health Center Clinic
Critical Access Hospital
Federal, State, or Local Government
Financial
Investment/Venture Firm
Healthcare Consulting Firm
Home Healthcare Org
Hospital
IDS/Hospital-Owned Ambulatory Clinic
Independent Ambulatory Clinic
Life Sciences
Long Term Care Facility
Payer
Professional Assn/Society
Public Health
Start-up
Vendor
*
Professional Role (select the best fit)
CEO, Chairman, Pres, Exec Dir, Adm, Group Practice Mgr
CFO, VP/Finance, Finance Director, Controller
Chief/Director of Other Clinical Depts./Lab Services/Pharmacy
CIO, VP of IT/IS
CMIO, CNIO, CCIO
CMO, Medical Director, Chief of Staff
CNO, VP/Director of Nursing
Compliance Officer; Compliance VP/Director/Manager
COO, Exec VP, Sr VP, VP, Gen Mgr
CSO, CISO, VP, Director Info Security/Site Security
CTO
Government Employee/ Public Servant
Healthcare Strategists
Hospitalist
IT, Business Consultant
Manager
Non-Management
Nurse
Nurse Practitioner
Patient Advocate
Physician's Assistant
Physician
Professor/Educator
Programmers / Developers
Project Manager
Registered Pharmacist
Senior Staff/Staff
Student
Systems Analyst
VP
Select your age range:
21 – 24
25 – 34
35 – 44
45 – 54
55 – 64
65+
Select years worked in the field:
<1 year
1 – 5 years
6 – 10 years
11 – 15 years
>15 years
*
Are you interested in participating in a mentor program?
Yes
No
*
Are you interested in serving as a
Mentee
Mentor
Both
*
Would you pay an annual fee to take part in a formal mentor program that includes a personal mentor?
No
Yes
*
What type of mentoring program are you interested in?
Virtual
In-person
Both
*
What topic(s) are you interested in discussing as a mentee/mentor?
Additional comments: