The Wonderful Thing About Life Is That You Cannot Succeed on Your Own (Or Fail on Your

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 ofSurgery 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:

1. Click in the grey box to fill in your responses; or
2. Click in the dropdown box to make your selection; or
3. 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 . Thank you.

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PART 1: Personal InformationToday’s Date:

Name: Degree (select one)SELECTPhDMDMD, PhDOtherAdditional or Other Degree(s) (Please List)

Primary Clinical Department: SURGERYMy Clinical Specific Area(s):

My secondary faculty appointment(for % of time) is in the:

Clinical Department of SELECTAnesthesiologyEmergency MedicineNeurologyFamily MedicinePsychiatry & Behavioral SciencesENTNeurological SurgeryPediatricsRadiation OncologyRadiologyInternal MedicineOphthalmologyPathology & Laboratory MedicineSurgeryUrological SurgeryOrhtopedic SurgeryRehabilitation MedicineObstetrics & Gynecology or Basic Science Department of SELECTAnatomy & Cell BiologyBiochemistry & Molecular BiologyMolecular & Integrative PhysiologyHealth Policy & ManagementHistory & Philosophy of MedicinePreventive Medicine & Public HealthPharmacology, Toxicology & TherapeuticsBiostatisticsMicrobiology, Molecular Genetics & Immunology

Track: (select one)If you are not sure, read Understanding Ranks & Tracks@

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 PROFESSORAssociate PROFESSOR

ClinicalASSISTANT PROFESSORClinical ASSOCIATE PROFESSOR

Research ASSISTANT PROFESSORResearch ASSOCIATE PROFESSOR

Years in Current Rank: (select one) 1-5 6-10 11-15 16-20 over 20

Years on the KUSoM Faculty: (select one) 1-5 6-10 11-15 16-20 over 20

Career Total Years as Faculty Anywhere: (select one) 1-5 6-10 11-15 16-20 over 20

Working, Leadership, Administrativeor Committee Title(s) other than your Academic Title:

1. 2. 3. 4. 5. 6. 7. 8.

Area(s) of Research Interest or Expertise: Current Grant Support (list sources only):

Current Committee Membership(s):

Office Telephone: (913) 588- Office Fax: (913) 588-

I do not use GroupWise for my calendar so please contact for meetings and appointments via:

E-mail Addressor Phone 8-

OPTIONAL (but helpful information)

Gender (optional): M FAge: 30-39 40-49 50-59 60+

Marital Status: Single Significant Other Married Divorced/Widowed

Children: yes noPlease 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
(listed in alphabetical order) / Check one box
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, selecting another sub-specialty) / 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
Area of Expertise: / YES NO Don’t Know
Clinical Administration (including staffing issues) / YES NO Don’t Know
Clinical Operations / YES NO Don’t Know
Clinical Research
Area of Expertise:
Desired Area of Collaboration: / 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
Communication Skills / YES NO Don’t Know
Conflict Management (handling “difficult” patients, colleagues, discussions or Administrators) / 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 chapters, contributions to published symposia) / 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

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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. Yes No
2. I made the initial contacted with my current mentor: Yes No
3. My mentor is from:
4. KUMC
5. 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.

______

SignatureDate

1. I would feel mostcomfortable working with:
2. MDPhD either
3. Professor Associate Professor Assistant Professor don’t care
4. Clinician Behavioral Scientist Basic Scientistdon’t care
5. Tenured Non-tenured don’t care
6. same gender same race/ethnic origin don’t care
7. Special needs of mine:
8. I would prefer to work with a mentor:

Weeklymonthly quarterly other

1. 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 toLaurie Woodvia email.

Email.

1. “Save as” using Mentee followed by your name. For example: Mentee_MMcLaughlin
2. Send the form as an attachment via email to Laurie , Administrative Officer, Department of Surgery.

Thank you.

1

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4/22/2011