First Name *

Last Name *

Institution *

Email *

Phone *

What is your institution type? *

Private University

Public University

Veterans Administration

Is your primary hospital owned by the University? *

Enter required value Yes No

Is your healthcare system fully academic, or a mix of private practice and academic? *

Enter required value Fully (100%) Academic Mixed

How many full-time academic faculty in your dept. at your institution (Numerical answer only) *

Does the Department include Child Neurology? *

Enter required value Yes No

Do you have Vice Chairs in your department? *

Enter required value Yes No

What is your residency size? *

Enter required value Small (4 or fewer residents per year) Medium (5-7 residents per year) Large (8 or more residents per year)

How many years have you been a Chair? *

Enter required value 4-5 years 6-10 years 10+ years

Were you the inaugural Chair for the Department? *

Enter required value Yes No

Were you mentored when you took on your current role? *

Enter required value Yes No

On what issues/areas do you feel you can provide mentoring? *

(Please list in order of importance. Example: Research Growth, Clinical Expansion, Funds Flow, etc.)

What challenges do you face? *

Please name any individuals would you prefer NOT to have as a mentee.

Additional Comments (optional)