Chair-to-Chair Coaching Pairing (Mentee)
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First Name *
Last Name *
Institution *
Email *
Phone *
What is your institution type? *
Private University
Public University
Veterans Administration
Is your healthcare system fully academic, or a mix of private practice and academic? *
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Fully (100%) Academic
Mixed
Is your primary hospital owned by the University? *
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Yes
No
Number of full time primary faculty *
Does the Department include Child Neurology? *
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Yes
No
What issues/areas do you most want to be matched for? (Please list in order of importance) *
What are three objectives you hope to get out of the coaching program? *
Please name up to 2 Chairs you would welcome as a Coach.
Please name any individuals would you prefer NOT to have as a Coach.
Additional Comments (optional)