Office of Professional Development Main MenuClose Main MenuClose Admissions About our School Programs Electives Students Residents Faculty Alumni & Friends News Events Research Directories Giving Tour Report Mistreatment Welcome Development Cultural Competency Diversity Faculty Improvement Improving Teaching Promotion Government Issues Meeting Minutes Lectureships SOM Humanities Medical Education Journal Club Research & Academia Faculty Awards Louise E. Arnold, PhD Excellence in Medical Education Research Award Betty M. Drees, MD Excellence in Mentoring Awards Christopher Papasian, PhD Excellence in Teaching Award Faculty Award for Excellence in Diversity and Health Equity in Medicine Faculty Clinical Affiliate Teaching Award Faculty Researcher Award Faculty Awards Review Committee members Awards Review Committee Bylaws News & Events Faculty Affairs Office of Faculty Affairs Faculty Events Faculty Council Publications Promotion & Tenure Faculty Council Committee – Meeting Minutes Contacts Christine Sullivan, MD Associate Dean for Professional Development sullivanchr@umkc.edu 816-235-1808 Jordan Callison Office Support Assistant Department of Faculty Affairs 816-235-1802 callisonj@umkc.edu Faculty Mentor Application This information will help pair you with an appropriate mentee. Mentors do not need to be from the samedepartment, division, section or affiliate as the Mentee; rather there will bea focus to pair Mentee-Mentors together who share similar academic goals.Your responses may be used for education research purposesto be shared as group data only (for example, tracking data responses by faculty rank type). No personal identifiers will be used. I give permission to have my responses shared as group data only for research purposes*Please selectYesNo In which mentoring program do you wish to serve as a Mentor (professors may choose multiple programs or “program of most need”)*Early career (Associate Professors and Professors eligible)Mid-career (Professors eligible)Longevity career (Professors eligible)Program of most need (Professors eligible) Name*FirstLast Degree* Email* Phone Current Position* Year started as School of Medicine (SOM) faculty*Select Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971 Current academic rank*Select RankAssistant ProfessorAssociate ProfessorProfessor Year(s) at this rank*012345678910111213141516171819202122232425262728293031323334353637383940414243444546474849 Your Academic department (and division/section as applicable):* Are you clinically active at one of the affiliates*Please selectYesNo If you are clinically active, which affiliate is your majority of time spent atSelect AffiliateTruman Medical CentersSaint Luke's HospitalChildren's Mercy HospitalCenter for Behavioral MedicineVeteran’s Administration HospitalResearch Medical CenterOther The majority of my time is focused on issues related to: (check top 1-2 choices)Undergraduate medical education focusedGraduate medical education focusedGraduate professions education focusedFaculty focusedClinical practice focusedOperations focused (Hospital/department/clinical/medical school, etc.) Research focusedOtherGoals Why do you want to participate in the mentoring program? (50 words or less)* What SOM scholarly activity focus area(s) do you feel most qualified to coach others in? (Choose up to 2)*TeachingServiceClinical PracticeResearchLeadershipOther Is there a specific style of mentee that would be most effective for you to work with? (please describe) (50 words or less) Are you able to serve as a sponsor for a mentee in a certain area (meaning, that you have regional/national influence/connections in certain organizations) that could serve to introduce/promote selected SOM mentees? *Please selectYesNo If yes, please describe As a Mentor you will need to commit to meeting with your Mentee at least 3- 4 times/year. How many mentees would you be willing to have? *Please select how many12345 What current committees/councils/activities are you involved with at the SOM? (50 words or less) What is your research/scholarly activity focus? Choose all that apply.Please selectEducation ResearchQuality improvementPatient safetyClinical ResearchBench ResearchOtherNone Provide a brief biosketch that includes why you want to be a faculty mentor and what current leadership and scholarly interests you have (please frame in regards to the promotion criteria: for example, for physician faculty: teaching, service, clinical practice, and research; for non-physician/non-clinical physician faculty: teaching, professional/clinical service, and advancement of knowledge [research]). (No more than 200 words). * I give permission to place my biosketch on the Office of Professional Development website as a Mentor. *Yes/NoYesNoThank you for participating.After your submission, the Office of Professional Development will be in touch with you to schedule an appointment based on availability.SubmitReset
