| UMKC School of Medicine

Longitudinal/On-going Mentoring Program Application

This information will provide background to guide mentoring/coaching sessions and help pair you with an appropriate mentor. It will serve as a template to track progress with your mentor and will be subject to updates/changes as your career progresses. Please be brief and clear in your responses you may choose to list (bullet) your responses instead of writing narrative responses. Your responses should be no more than 50-100 words (and often less) for many questions.

I give permission to have my responses shared as group data only for research purposes*

Mentoring program are you requesting*

Early

Mid-Career

Longevity

Name*

First

Last

Email*

Phone

Current Position*

Next/Desired Position*

Year started as School of Medicine (SOM) faculty*

Current academic rank*

Year(s) at this rank*

Are you clinically active at one of the affiliates*

If you are clinically active, which affiliate is your majority of time spent at

Please upload a copy of most recent CV.

Goals

Why do you want to participate in the mentoring program?*

What do you hope to learn from your mentor?*

Is there a specific style of mentee that would be most effective for you to work with? Do you have someone specifically in mind? (please describe) (50 words or less)

What are your professional goals for the next year?*

What are your professional goals for the next 5 years?*

What is your ultimate professional goal?*

For promotion and fulfillment, which scholarly activity categories (Teaching, Service, Clinical Practice, Research) most interest you and why? *

Teaching

What type of teaching are you currently doing (classroom, clinical, etc.) and to whom (what type of learners do you work with)?*

Have you presented at regional/national level, if so, briefly describe and how recently? (leave blank if none)

What type of teaching do you want to be doing?*

Service

What current committees/councils/activities are you involved with at the SOM? (leave blank if none)

What current committees/councils/activities are you involved with at the hospital/your clinical affiliate(s)? (leave blank if none)

What committees would you like to serve on?

Do you currently have any leadership roles? (if yes, please describe)

What leadership roles are you hoping to obtain?

Clinical Practice (if applicable)

What is your current clinical role?

Do you direct a clinical program, devise new methods/procedures for clinical care? (if yes, please describe)

Research

Do you have at least one peer-reviewed publication (indexed in PubMed or SCOPUS)? (If applicable, do you have at least one peer-reviewed publication since last promotion)?

Have you obtained research funding/grants/serve as a PI of single/multi-center trial? (if so, please describe)

Do you serve as a journal reviewer, journal editor, grant reviewer, etc? (if so, please describe)

Have you presented high quality research at regional/national meetings? (if so, please describe)

Self-Reflection

Regarding promotion and/or other goals, briefly describewhat you believe to be your strengths and weaknesses (areas to take advantageof and areas to focus on/correct), opportunities that have been presented toyou or that you think you would like to take advantage of, and any perceivedthreats to your success.

SWOT Analysis

S - Strengths

W - Weaknesses

O - Opportunities

T - Threats

SMART Goals

Please initially complete but will be an area to furtherdevelop during your Mentor meetings.Thepurpose is to identify a few specific goals to progress your professionalcareer, fulfillment, and promotion.

S—Specific—definespecific results and concrete details on what is to be achieved

M—Measurable goals—definehow success will be measured (as applicable:quantity (increase/decrease in something); quality (how well the resultmeets the goal); efficiency (resources applied to achieve the result); behavior(observable/measured change)

A—Attainable—challengingand go beyond current day-to-day duties; achievable with resources available; may require developing new skills and changing attitudes

R—Relevant—statethe results achieved rather than the activity to lead to result

T--Time bound—realistic,committed time-frame to achieve the goal

Write the goal you have in mind

Specific - What do you want to accomplish? Who needs to be included? When do you want to do this? Why is this a goal?

Measurable - How can you measure progress and know if you’ve successfully met your goal?

Acheivable - Do you have the skills required to achieve the goal? If not, can you obtain them? What is the motivation for this goal? Is the amount of effort required on par with what the goal will achieve?

Relevant - Why am I setting this goal now? Is it aligned with overall objectives?

Time-Bound - What’s the deadline and is it realistic?

Based on what you have written, would you like to revise/add to what you would specifically hope to gain from participating in the mentorship program? Please list (limit to 50 words)