Transplant Mentor Application - Due February 1, 2019

This application is for professionals working at transplant programs, who are interested in offering their time and expertise to be mentors to other transplant professionals new in their role or new to transplant. Thank you for your time.

REQUIRED

Salutation

*

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First Name*

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Last Name*

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Email*

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Best Phone Number to Reach You*

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Transplant Center*

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City*

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State*

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Type of Education Degree(s) Achieved

*






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Education: Degree(s) Achieved*

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Current Professional Certifications*

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Current Transplant Position*

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Years in Current Position*

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What category describes your position?

*








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Patient groups - please check all patient groups that you care for:

*

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Areas of Transplant: Please indicate all areas that you cover with your current role.

*

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Organs you work with in your current role:

*

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Previous Transplant Positions*

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Years of Total Transplant Experience*

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Experience in Areas of Transplant - Please indicate which areas of transplant you could mentor based on your current and previous transplant experiences.

*

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Organs you have worked with in the past that you could cover in mentorship:

*

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Do you or have you ever taken call in transplant?

*

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Do you have prior mentorship experience?

*

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If yes, please describe your experience

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What personal characteristics do you have that will contribute to your ability to be a mentor? *

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How do you hope to benefit from being a mentor in this program?*

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How do you expect your mentee to benefit from this program? *

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Which type of mentorship would you like to provide? (check all that apply)

*



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If you selected to provide one-on-one mentorship, can you commit to being a mentor for a minimum of one year?

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If you selected to provide one-on-one mentorship, can you commit to communicating with your mentee for at least 2 hours per month?

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If you committed to situational mentorship, please indicate all areas of transplant that you are comfortable mentoring





































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Are you willing to have more than one mentee at the same time?

*

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Please provide a professional reference: (Name, Position, Transplant Center, Phone, Email)*
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