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Required format:

2024 Mentor Academy Application

Returning?

A A A

Thank you for your interest in the 2024 CTSI Mentor Academy. Please complete the following application to provide us with information about your research and mentoring experience and your goals for participating in the program.

Great News! The application deadline has been extended. Applications are now due on Friday, November 10th, 2023 and will be reviewed by members of the CTSI Education Administration and Oversight Committee.

If you would like to SAVE and RETURN you can do so. Record the return code so you can resume where you left off.

Sessions will be held in synchronous virtual format, except the first and last sessions anticipated to be held in person. The exact dates of sessions will be determined based on participant availability.

For your reference, you can download the 2024 Mentor Academy RFA here.

Attachment:2024 Mentor Academy RFA-final Extended Deadline 10 24 23.pdf

First Name

* must provide value

Last Name

* must provide value

Credentials

* must provide value

Academic Title

* must provide value

If you are an Assistant Professor or chose 'Other', please indicate any training grants or programs for which you are listed as a mentor or serve as a member of the training program administrative team or leadership.

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Department

Location (Market)

* must provide value

Other Location (Market)

* must provide value

Describe your current engagement in research.

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Describe your experience in mentoring.

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Please complete the Baseline Mentor-Mentee Relationship Table below. Enter number and/or percentage of total mentees.

What kinds of trainees are you currently mentoring in a research context?	Number	Percentage
Senior Faculty
Junior Faculty
Postdoctoral fellows
Clinical Fellows
PhD or Master's students
Medical or health care professional students (including residents, interns)
Postbaccalaureate students
Undergraduate students
High school students
K awardees
T awardees
I am not currently mentoring any trainees.

Why are your interested in participating in the Mentor Academy?

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Describe any prior formal or informal mentor training.

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If you are participating as a mentor in any formal mentoring programs, either institutionally or nationally, please indicate which ones. Check all that apply.

WFUSOM Women in Medicine and Science

WFUSOM Early Career Women Faculty Mentoring Program

CTSI KL2, TL1 or TRA

National Research Mentoring Network

Mentoring programs offered through Faculty Affairs

Other formal mentoring program

If OTHER, please give name of program(s).

What specific mentoring knowledge and skills you would like to enhance by participating in the Mentor Academy?

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How did you learn about the Mentor Academy? Check all that apply.

Personal email notification from CTSI

CTSI website

CTSI Research Rundown Newsletter

Faculty Links or eBulletin

Recommended by my section head or department chair

Discussed at a departmental or institutional meeting

Word of mouth from a prior participant

Other

If OTHER, how did you learn about the Mentor Academy?

I agree to attend at least 80% of the Mentor Academy sessions.

Yes

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Please upload a Letter of Support from your Department Chair assuring release time to participate in the 6-month program, if selected.

Upload file

Gender: How do you self-identify your gender?

* must provide value

Male

Female

Non-binary

Prefer to self-describe

Do not wish to provide

reset

Gender self-describe

* must provide value

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Race: How do you self-identify your race? Check one or more.

* must provide value

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Prefer to self-describe

Do not wish to provide

Race self-describe

* must provide value

Ethnicity: Do you identify as Hispanic or Latinx?

* must provide value

Yes

Do Not Wish to Provide

reset

Disability: Do you have a disability?

* must provide value

Yes

Do Not Wish to Provide

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If yes, which of the following categories describe your disability(ies)?

Mobility/Orthopedic Impairment

Hearing

Visual

Other

Other disability

* must provide value

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.