Medical Student Research Faculty Mentor Form

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The Faculty Mentor Form is used to survey IUSM faculty member's potential participation as a mentor to students who are P1Y1 to P3Y4 as well as IUSM research training programs such as IMPRS (summer research) and MedSTAR (gap year research). Please complete and submit the form to be included on the webpage https://md.mednet.iu.edu/research/imprs/faculty-mentors/.

If you have questions, please contact us at imprs@iupui.edu.

Faculty First Name

Faculty Last Name

Degrees

Rank

Title

Department

Campus

E-mail

Type of Research (Check all that apply)

* must provide value

Laboratory/Translational

Clinical

Community Based

Education

Health Research Outcomes

Informatics

Other

Other Type of Research

Area of Research (Check all that apply)

* must provide value

Addiction

Allergy/Infectious Disease

Autoimmune Disease

Biochemistry

Biological Imaging

Biomedical Engineering Research

Blood/Hematology

Bone Biology

Cancer Biology

Cardiovascular disease

Clinical Pharmacology

Community Health Engagement

Dermatology

Developmental Biology

Diabetes

Educational Research

Endocrinology

ENT

Gene Therapy

Genetics

Genomics/Pharmacogenetics/Pharmacogenomics

Gastroenterology/Hepatology

Global Health

Implementation Science

Medical Informatics/Bioinformatics

Microbiology/Immunology

Musculoskeletal

Neuroscience

Neurosurgery

OB/GYN

Orthopaedic

Ophthalmology

Personalized Medicine

Pediatrics Research

Pediatric Gastroenterology

Pediatric Rheumatology

Pharmacology and Toxicology

Plastic Surgery

Pulmonary Diseases

Psychiatric Disease

Radiology/Imaging Sciences

Stem Cell Biology

Surgery

Urology

Vascular Biology

Other

Other Area of Research

What level medical student would you prefer to mentor? (Check all that apply)

* must provide value

First Year

Second Year

Third Year

Fourth Year

No Preference

What is the expected time committment for the mentee? (Check all that apply)

* must provide value

Short Term Training (2 to 10 hours a week while student in school)

Summer Research (10 to 12 weeks in the summer)

Gap Year Research ( typically May to the following April; 10-11 months)

No Preference

What type of project or role/responsiblities for the mentee?

* must provide value

Clinical Study

Laboratory Study

Literature Review

IRB

Data Collection/Analysis

Other

Other (Project/Roles/Responsibilities)

Would you like to have IUSM medical students (rising MS2) working/training/learning in your lab for a 10-week program during the after their first year?

Yes No

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If you are interested to mentor a medical student during the summer, do you agree to be available and/or have a co-mentor such as post-doc fellow, lab manager, resident, graduate student etc. be available for mentorship if you are away?

* must provide value

Yes No

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If you are interested in mentoring, how many student(s) are you able to accomodate in your lab/group/project to provide them with a valuable eductional and mentored research experience (i.e. with regular contact, mentoring, distinct project)?

* must provide value

One Two Three Four or more

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What type of medical students do you prefer to be matched with for the mentoring?

* must provide value

Have research experience Have some research experience Do not have any research experience No preference

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Do you currently have your own laboratory or clinical space for research?

Yes No

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What is the current number of personnel in your laboratory?

None 1 2 3 4 or more

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What are the positions in your laboratory? (Check all that apply)

Technicians

Postdoctoral scientists

Graduate students

Undergraduate students

Have you previously mentored IUSM medical students?

Yes No

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Which type of program did they student particpate?

Summer Research (i.e. IMPRS) Gap Year Program (i.e. MedSTAR) Other

If yes, indicate who (student's name) and when (year).

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Please upload your CV or NIH biosketch.

Upload file

Comments/Project Description

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