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

Does the Department include Child Neurology? *

Enter required value Yes No

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

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 sites do your residents cover? (Numerical answer only) *

How many years have you been a Program Director? *

Are you a Vice Chair for Education? *

Enter required value Yes No

What experiences have you had? *

Enter required value Started a new program Expanded a program Neither

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.)

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

Additional Comments (optional)