Faculty Mentoring Program – Department of Surgery
NEED/DESIRE ASSESSMENT SURVEY for MENTEES
IF YOU ARE A JUNIOR MEMBER OF THE FACULTY IN THE SCHOOL OF MEDICINE, Department of Surgery
AND WISH TO WORK WITH A MENTOR, FOLLOW THESE DIRECTIONS.
DIRECTIONS:
This form is in 3 parts,
1) Your Personal Information
2) A Mentoring Interest Check-list
3) Your Preferences for a Mentor
It’s simple to complete:
a. Click in the grey
box to fill in your responses; or
b. Click in the dropdown box to make your selection; or
c. Click on one selection box
per question.
Please complete the MSWORD form, by 6/1/2011 and once completed:
“Save as” using Mentee followed by your name. For example: Mentee_MMcLaughlin
Send the form as an attachment via email to Laurie Wood [email protected]. Thank you.
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Today’s Date:
PART 1: Personal Information
Name:
Degree (select one) SELECT
Additional or Other Degree(s) (Please List)
Primary Clinical Department: SURGERY
My Clinical Specific Area(s):
My secondary faculty appointment (for
% of time) is in the:
Clinical Department of SELECT or Basic Science Department of SELECT
Track: (select one) If you are not sure, read Understanding Ranks & Tracks @
http://www.kumc.edu/som/facdev/immentoring/understanding_ranks_and_tracks.html
Tenure Track
Clinical Track (non-tenure)
Research Track (non-tenure)
Clinical Scholar Track/ Clinician-Educator Pathway (non-tenure)
Clinical Scholar Track / Clinician-Investigator Pathway (non-tenure)
Rank (Academic Title) Check ONE:
Assistant PROFESSOR
Associate PROFESSOR
Clinical ASSISTANT PROFESSOR
Clinical ASSOCIATE PROFESSOR
Research ASSISTANT PROFESSOR
Research ASSOCIATE PROFESSOR
Years in Current Rank: (select one)
1-5
6-10
Years on the KUSoM Faculty: (select one)
1-5
11-15
16-20
6-10
Career Total Years as Faculty Anywhere: (select one)
11-15
1-5
over 20
16-20
6-10
over 20
11-15
16-20
over 20
Working, Leadership, Administrative or Committee Title(s) other than your Academic Title:
1.
2.
3.
Area(s) of Research Interest or Expertise:
4.
5.
6.
7.
8.
Current Grant Support (list sources only):
Current Committee Membership(s):
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4/22/2011
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Faculty Mentoring Program – Department of Surgery
NEED/DESIRE ASSESSMENT SURVEY for MENTEES
Office Telephone: (913) 588-
Office Fax: (913) 588-
I do not use GroupWise for my calendar so please contact
E-mail Address
for meetings and appointments via:
or Phone 8-
OPTIONAL (but helpful information)
Gender (optional):
M
Marital Status:
Children:
F
Age:
Single
yes
30-39
40-49
Significant Other
no
50-59
Married
60+
Divorced/Widowed
Please list ages:
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PART 2: Mentoring Interest Check-list
Check your level of need or desire for mentoring in the areas or duties listed below.
YES – I need or would like mentoring in this area
NO – I do feel I need or am interested in mentoring in this area
Don’t Know – I am not sure if I need mentoring but would like to discuss the option
MENTORING TOPICS
Check one box
(listed in alphabetical order)
Academic Administration
YES
NO
Don’t Know
Advocate for career development (e.g. Career Skills)
YES
NO
Don’t Know
Availability for career guidance (e.g. selecting the right track,
YES
NO
Don’t Know
Availability for guidance on research efforts
YES
NO
Don’t Know
Balancing Personal/Professional Life
YES
NO
Don’t Know
Budgets (e.g. creating, understanding, following)
YES
NO
Don’t Know
Clinical /Patient Care
YES
NO
Don’t Know
Clinical Administration (including staffing issues)
YES
NO
Don’t Know
Clinical Operations
YES
NO
Don’t Know
Clinical Research
YES
NO
Don’t Know
Clinical Teaching Skills
YES
NO
Do ’t Know
Collaborative Research
YES
NO
Don’t Know
Committees, councils, boards – meaningful services
YES
NO
Don’t Know
selecting another sub-specialty)
Area of Expertise:
Area of Expertise:
Desired Area of Collaboration:
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Faculty Mentoring Program – Department of Surgery
NEED/DESIRE ASSESSMENT SURVEY for MENTEES
Communication Skills
YES
NO
Don’t Know
Conflict Management (handling “difficult” patients, colleagues,
YES
NO
Don’t Know
Dealing with ethical dilemmas in clinical encounters
YES
NO
Don’t Know
Developing a Curriculum Vitae
YES
NO
Don’t Know
Developing a teaching portfolio
YES
NO
Don’t Know
Education/Teaching
YES
NO
Don’t Know
Encouragement to submit abstracts/grants
YES
NO
Don’t Know
Faculty Governance
YES
NO
Don’t Know
Finding a niche on medical campus
YES
NO
Don’t Know
Grant-writing skills
YES
NO
Don’t Know
Institutional Networking
YES
NO
Don’t Know
Integrating research and clinical activities
YES
NO
Don’t Know
Interdisciplinary Research
YES
NO
Don’t Know
Listening Skills
YES
NO
Don’t Know
Manuscript Writing/Review
YES
NO
Don’t Know
National Networking
YES
NO
Don’t Know
Navigating Political Waters
YES
NO
Don’t Know
Negotiating Skills
YES
NO
Don’t Know
Presentation Skills
YES
NO
Don’t Know
Publishing (e.g. manuscript review, authorship of book
YES
NO
Don’t Know
Resident teaching and evaluation
YES
NO
Don’t Know
Sharing same gender/ethnic background
YES
NO
Don’t Know
Time management, setting priorities and organization skills
YES
NO
Don’t Know
Timing pregnancy/childcare
YES
NO
Don’t Know
Understanding the promotion process
YES
NO
Don’t Know
Other -- Please describe:
YES
NO
Don’t Know
discussions or Administrators)
chapters, contributions to published symposia)
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Faculty Mentoring Program – Department of Surgery
NEED/DESIRE ASSESSMENT SURVEY for MENTEES
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PART 4: Check-List for Working with a Mentor
Please complete all questions.
1. I am working with a Mentor now, in an informal situation.
a. I made the initial contacted with my current mentor:
Yes
No
Yes
No
b. My mentor is from:
i.
KUMC
ii.
Outside KUMC (additional info optional)
I understand, as a faculty member in the Department of Surgery, I may be assigned a Mentor from within the
department and possibly from another department within KUMC, or more than one, based on my needs.
_______________________________________________________
Signature
_________________________
Date
2. I would feel most comfortable working with:
a.
MD
PhD
b.
Professor
Associate Professor
Assistant Professor
c.
Clinician
Behavioral Scientist
Basic Scientist
d.
Tenured
Non-tenured
e.
same gender
f.
either
don’t care
don’t care
don’t care
same race/ethnic origin
don’t care
Special needs of mine:
3. I would prefer to work with a mentor:
Weekly
monthly
quarterly
other
4. In terms of managing a relationship with my mentor, my style would be:
Passive – they need to take the lead
Aggressive – I tend to take the lead
I’m flexible with their personality
I don’t know
Comments:
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When you have completed the form, please submit the form to
Laurie Wood via email.
Email.
a. “Save as” using Mentee followed by your name. For example: Mentee_MMcLaughlin
b. Send the form as an attachment via email to Laurie Wood [email protected], Administrative Officer,
Department of Surgery.
Thank you.
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4/22/2011
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