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I3 Mentee Baseline Survey

Returning?

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Thank you for participating in the I3 Mentoring Program. Please complete this survey as a mentee entering the program. This survey collects valuable baseline measures. We appreciate your contribution to this program.

Date: (MM/DD/YY)

Your last name

* must provide value

Your first name

* must provide value

Your primary mentor's last name

Your primary mentor's first name

Race:

Gender:

Degree(s):

Year of hire as faculty at IUSM:

Department, Division, Center, or Unit:

Rank:

Track (Tenure or Clinical)

Additional roles, titles, leadership positions:

Research %

Teaching %

Clinical %

Administration %

Other %

Thinking generally about your satisfaction with your career in academic medicine, would you say that you are currently:

I appreciate the value of developing a mentoring relationship.

I believe a mentoring relationship can enhance or improve my overall career satisfaction.

I believe a mentoring relationship can have a positive impact on my career success.

I believe a mentoring relationship can help in my personal development.

I believe mentoring is valuable to advance the mission of the institution.

I feel confident in my ability to identify and approach individuals for mentoring.

I feel confident in my ability to navigate and maintain a mentoring relationship.

Concerning the current status of your GRANT FUNDING, please check all that apply and provide details for each.

Grants awarded

Grants submitted, under review

Grants submitted, not funded (score, percentile, resubmitted)

Other funding sources

Please list the details of your GRANTS AWARDED:

Please list the details of your GRANTS SUBMITTED, under review:

Please list the details of your GRANTS SUBMITTED, NOT FUNDED (including score, percentile, and whether it was resubmitted):

Please describe other funding sources:

In the past 12 months, I have accomplished the following SCHOLARSHIP OUTCOME(S):

Manuscript submission

Manuscript publication (peer reviewed)

Publication (non-peer reviewed)

Book chapter

Poster presentation

Oral presentation

New research method

New teaching method

Implementation of a new program (clinical, educational, research, service)

Web-based program development & implementation

New protocol development & implementation

Other:

Please list your manuscript publications (peer reviewed):

Please list your publications (non-peer reviewed):

Please list your book chapter(s):

Please describe "Other":

In the past 12 months, I have had the following CAREER ADVANCEMENT(S):

Promotion (rank, tenure)

Recognition (honor, award)

Leadership position

Grant funding

Additional training opportunity/ degree

Consulting activity

Invited presentation

Committee involvement

Other:

Please tell us your Promotion (rank, tenure):

Please list your Recognition (honor, award):

Please tell us your Leadership position:

Please describe your additional training opportunity/degree:

Please describe your consulting activity:

Please describe "Other":

In the past 12 months, I have participated in the following PROFESSIONAL DEVELOPMENT activities to enhance my academic skills?

OFAPD event (FEED, LAMP, P&T session)

CTSI event

CTL (Center for Teaching and Learning) event

Scientific writing workshop

Grant writing workshop

National conference

Other

Please describe "Other":

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.