ASMBS Integrated Health Mentorship Program

Integrated Health Mentorship Program Application

"*" indicates required fields

I am interested in becoming an ASMBS IH...*

At this time, we are asking respondents to select one option. Additional questions based on selection.

Mentee

Mentor

Personal and Professional Information

Name*

First Last

ASMBS Member ID*

Preferred Email Address*

Enter Email Confirm Email

Preferred Contact Phone Number*

Current Institution/Hospital*

What best describes your gender?*

Female

Male

Transgender/Trans woman

Transgender/ Trans man

Non-binary/third gender

Prefer not to reply

Other

With which racial group do you identify?*

Select all that apply.

Asian

Black, African, African American, or Afro-Caribbean

Middle Eastern or North African

Native American or Alaskan Native

Native Hawaiian/other Pacific Islander

White

Prefer not to reply

Other (describe)

Other Racial Group*

With which ethnic group do you identify?*

Select all that apply.

Hispanic/Latinx

Non-Hispanic/Latinx

Other

Prefer not to reply

What is your age group?*

Under 30 years old

30-39

40-49

50-59

60-69

70 years of age and older

In which type of setting do you work?*

Select all that apply.

Community-based Program

Government (non-military)

Hospital-based Program

Military (e.g., Veterans Affairs)

Private Practice

Rural

University/ Academic Program

What role do you hold in your work in the metabolic and bariatric surgery field?*

Select all that apply.

Other Work Role*

How many years have you been in practice in your discipline?*

Less than 2 years

2-4 years

5-8 years

> 8 years

Retired

How many years have you worked in the metabolic and bariatric field?*

Less than 2 years

2-4 years

5-8 years

> 8 years

Retired

Mentee Questions

Rank Interests

Please select focused interests for the mentoring year. This will help us match you with a well-suited mentor. Place your highest priority at the top. Drag each item.

Clinical Skills/Expertise
Engagement, Inclusion and Diversity Support
Leadership Skills
Personal Growth
Programmatic/Systems-Related Skills and Expertise
Academic Skills/Expertise

For those interests above, please rank the importance for receiving mentorship within each category. Place the highest interests at the top of each list.

Clinical Skills and Expertise

Rank the importance for receiving a mentorship within this category. Place the highest interests at the top of the list. Drag each item.

Building Clinical Confidence
Clinical Teaching/Supervision
Direct Patient Care
Integrating Clinical and Research Activities
Other

Other Clinical Skills and Expertise

Engagement, Inclusion and Diversity Support

Rank the importance for receiving a mentorship within this category. Place the highest interests at the top of the list. Drag each item.

Addressing Microaggressions/Implicit Bias at Workplace
Addressing Burnout
Becoming an Effective Teacher to Students/Residents/Fellows
Overcoming Imposter Syndrome
Other

Other Engagement, Inclusion and Diversity Support

Leadership Skills

Rank the importance for receiving a mentorship within this category. Place the highest interests at the top of the list. Drag each item.

ASMBS Leadership Growth
Building a Collaborative Environment in Program/Practice
Conflict Resolution with Staff and/or Colleagues
Hospital Leadership
Institutional and Professional Service (Committees, Boards, Councils)
Other

Other Leadership Skills

Personal Growth

Rank the importance for receiving a mentorship within this category. Place the highest interests at the top of the list. Drag each item.

Work-life Balance
Work-family Balance
Other

Other Personal Growth

Practice Growth

Rank the importance for receiving a mentorship within this category. Place the highest interests at the top of the list. Drag each item.

Programmatic/Systems-Related Skills and Expertise Budgets
Clinical Pathways/Operations
Developing a MBSAQIP Program
Increasing Patient Engagement
Marketing Strategies
Navigating the Insurance Process
Program Development
Other

Other Practice Growth

Academic Skills and Expertise

Rank the importance for receiving a mentorship within this category. Place the highest interests at the top of the list. Drag each item.

Academic Promotion
Developing a CV
Grant Writing
Manuscript Writing
Presentation Skills
Research Guidance
Other

Other Academic Skills and Expertise

What other areas would be beneficial for a mentor to address?

Mentor Preferences

Please note, while every effort will be made to match mentors and mentees to the best of our ability, we may not be able to match on all preferred dimensions.

Are you interested in receiving mentorship from an IH Member who works in a different discipline than your discipline? If so, please select the disciplines with which you would feel comfortable receiving mentorship.*

Select all that apply.

Other Different Discipline*

Gender Preference in a Mentor*

Select all that apply.

Female

Male

Transgender/Trans woman

Transgender/ Trans man

Non-binary/third gender

No preference

Race/Ethnicity Preference in a Mentor*

Select all that apply.

Asian

Hispanic/Latino/a/Latinx

Middle Eastern or North African

Native American or Alaska Native

Native Hawaiian/other Pacific Islander

Non-Hispanic White or Caucasian

Non-Hispanic Black, African, African American or Afro-Caribbean

No preference

Other (describe)

Other Race/Ethnicity Preference in a Mentor

Select the qualities below based on their importance for your ideal mentor match.

Drag the options to set your rank regarding your mentor preference. Place the highest preference at the top. Drag each item.

Academic Medicine
Community-based Medicine
Ethnicity/Race Preference in a Mentor
Gender Preference in a Mentor
LGBTQ Preference in a Mentor
Mentor Involved in ASMBS Leadership
Mentor Involved with Hospital Leadership
Mentor within the Same Discipline
Military Background
Private Practice
Other

Other Qualities Preference

Please answer the following questions:

What assets, skills or experiences are you most proud of?*

2-3 sentences.

What are the three most important goals you hope to achieve in the next 12 months - 2 years?*

3-4 sentences.

Identify the key elements needed to achieve these goals in general.*

2-3 sentences.

Are there any deficits in your training, skills or experience that could impede your success? How might mentoring help with this?*

1-2 sentences.

What aspects of work do you find challenging, or that make you feel drained or stressed? (e.g., teaching students, time management).*

1-3 sentences.

Have you had a mentor before? If so, what has contributed to a successful or challenging mentor-mentee relationship?*

1-3 sentences.

What are the top three things you feel you need from your mentor to achieve your professional goals?*

1-3 sentences.

Will you commit to meeting (at minimum) quarterly with your mentor, completing a mid-year and end of the year short survey, and submitting an action plan?*

Yes

What is your preference for the frequency of meetings with your mentor?*

Weekly

Monthly

Quarterly

Other

What methods of communication best fit your preference for communication with your mentor?*

Select all that apply.

Phone calls

Text messaging

Video conferencing/video chat (e.g. Zoom, FaceTime, Skype, Microsoft Teams)

Chats via Messenger (Whatsapp, Facebook Messenger)

Upload CV*

Accepted file types: docx, pdf, Max. file size: 8 MB.

Statement of Diversity and Inclusion: Our mentorship program is committed to inclusion and diversity. We take affirmative action to ensure equal opportunity for all participants regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, Veteran status, or other legally protected characteristics. By agreeing to participate in our mentorship program you are therefore agreeing to our principles of diversity, equity, and inclusion.

Confidentiality Agreement: Mentorship is built on a solid foundation of trust and respect. Unless directed otherwise by the mentee or mentor, and with explicit permission to share information outside of the mentee-mentor pair, conversations are to remain confidential. Any concerns regarding mentor or mentee behavior should be reported to the IH Multidisciplinary Care Committee. If concerns arise regarding the safety of the mentor or mentee, potential reporting to professional licensing boards may occur. Applications are to remain confidential and only selected members of the Multidisciplinary Care Committee and assigned liaisons will have access to applications for pairing purposes. By entering the mentorship program, you agree to abide by these confidentiality rules. Advice and recommendations regarding patient clinical scenarios should not be used as official consultation for patient care. Mentors and mentees may request a different pairing at any time during the program and will be rematched if available pairings are likely to be a good fit.

Consent Agreement*

I agree to abide by the Statement of Diversity and Inclusion and Confidentiality Agreement.

Mentor Section

Have you acted as a formal or informal mentor for a junior colleague or trainee in your specialty area?*

Yes, for an individual within my institution/program

Yes, for an individual outside my institution/program

Yes, for individuals within and outside my institution/program

Please rank the areas of expertise you feel you can best support a mentee with these interests. Drag each item.

Place your highest priority on top.

Clinical Skills/Expertise
Engagement, Inclusion and Diversity Support
Leadership Skills
Personal Growth
Programmatic/Systems-Related Skills and Expertise
Academic Skills/Expertise

For those interests above, please rank your importance in mentoring a mentee within these areas of development. Place the highest interest at the top of each list.

Clinical Skills and Expertise