2019 EAST Mentoring Program - Mid-Level Career Mentor Application

Thank you for your interest as an Mid-Level Career Mentor in the EAST Mentoring Program.  The goal of the Mentoring Program is to promote the academic and personal growth of the young trauma and acute care surgeon by providing extramural mentorship over a 1-year period. 

New this year!  The 2019 program is implementing a multi-tiered approach to mentoring including a team of early career, mid-level career and senior career medical professionals to form a four-person “Mentoring Family”.  Additional information regarding the program structure can be seen here.

Mid-Level Career Mentor Requirements:

1. You must be an EAST member (Active, Associate) in good standing and membership dues paid in full by June 30, 2019.

2. You must be either an Active or Associate member of EAST who is more than 5-years out of training.

3. Complete the below online application and upload your curriculum vitae (CV) for matching purposes.

The EAST Mentoring Committee will match and send communications regarding your assigned "Mentoring Family" in September 2019.

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Mid-Level Career Mentor Information

Full Name*

Include full name and degrees/credentials

Email Address*

Institutional and/or Military Affiliation*

Position*

EAST Membership Type/Category*

Active or Provisional or Associate or Fellow

Are you currently a...*

• Resident
• Fellow in Surgical Critical Care, Trauma, or Acute Care Surgery
• Within five years of completion of training
• Other

If Other, please indicate:

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Personal Statement

In 2-3 sentences explain why you want to participate in the Mentoring Program.*

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Mentorship Information

What is the primary area you would like to strengthen via the EAST Mentoring Program?*

• Research
• Administrative
• Education
• Mgmt. of Difficult Situations: Work-life Balance, Communication, Promotion, Negotiation
• Other

If Other, please define:

Is practice setting important criteria to you in your mentorship?*

• Yes
• No

If Yes, what practice setting would prefer for your mentorship [check all that apply]?

• Academic
• Community
• Private
• Urban
• Rural
• Military
• Other

If Other, please define:

Have you ever had a Military Affiliation?*

• Yes
• No

If Military Affiliation, what branch? Are you Active? Length of Service?

If you have Military Affiliation, are you looking for a Mentor with Military experience?

• Yes
• No
• N/A - I have no Military Affiliation

If you have Military Affiliation, is service affiliation important criteria to you in a Mentor?

• Yes
• No
• N/A - I have no Military Affiliation

If you have Military Affiliation, would you like a Mentor to facilitate with [check all that apply]:

• Your transition to civilian practice
• Your decision regarding continued Military service
• Your interest to move to senior leadership roles in Military service
• N/A - I have no Military Affiliation

If you have Military Affiliation, would you prefer...

• Mentor currently serving in Military
• Mentor that has transitioned to civilian practice
• N/A - I have no Military Affiliation

Is geographic proximity an important factor with regards to your mentorship?

• Yes
• No

How frequently would you be interested in communicating during your mentorship?*

• Weekly
• Monthly
• Quarterly
• Annually

If Other, please define:

I would like to build a reputation that is:*

• Local
• Regional
• National
• International

Do you have a gender preference for Mentors?*

• Yes
• No

If yes, please indicate what your Mentor gender preference is...

Additional Information

List any additional information, concerns, or issues that you feel is relevant to your mentorship.

Please upload a copy of your CV*

Accepted Formats: .pdf, .doc, .docx, .png, .jpg

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