UCSF Clinical & Translational Science Institute
Mentor Development Program
Sample Individual Development Plan: Pediatrics
1. Name:
2. Review period: MM/YY to MM/YY
or Other:
Date submitting form: MM/DD/YY
3. Fellow Contact Information:
Tel (h)
(w)
Cell
Beeper
Email (UCSF)
Email (Other)
Division Administrative Assistant Contact Information: Name:
Tel (h)
(w)
Cell
Email
Affiliations: ○ MMP ○ PSDP ○ CVRI Other:
4. Departmental/Division Appointment (Main)
Year of Fellowship:
○1
○2
5. FELLOWSHIP SUPPORT
A. Funding
Yes
No
Year 1
○
○
○3
Don't Know
○
Year 2
○
○
○
Year 3
○
○
○
○other
Source(s): (e.g., NIH, T-32, K)
B. If no current known source of funding what are the plans for support:
6. Post-graduate degree(s): ○ MPH ○ MS/MA ○ PhD ○ Other:
Fast-tracking fellowship? ○ Yes
○ No; If Yes, have ABP approval? ○ Yes
7. LONG-RANGE GOALS
A. List:
○ No
B. What is your career track? (Choose one)
○ Physician Research Scientist
○ Physician Educator Scientist
○ Consulting Master Clinical Subspecialist
○ Research Scientist (PhD, other non-clinician)
○ Other (explain)
○ Undecided
8. SHORT-RANGE GOALS
A. Specific short-range goals for current academic fellowship year (Years 1-3):
B. Specific short-range goals for next 12 months of fellowship (Year 1 only):
9. YEAR IN REVIEW
A. Thinking back to your short term goals for this academic year, what have you accomplished to date in
each of the areas of effort listed?:(List work products under 13)
Research Activities:
Patient Care (Clinical Activities):
Professional Self-Development (Training Activities):
Education (Teaching Activities): (maybe 0%)
Administration:
Other Professional Accomplishments:
B. Formal Coursework:
UCSF Clinical & Translational Science Institute
Mentor Development Program
Sample Individual Development Plan: Pediatrics
Page 2 of 2
C. Distribution Areas of Effort This Past Year (See instructions for definitions)
Estimate (averaged over this current year under review) your distribution of effort by approximate
hours/month. Next, give us your ideal distribution. Finally, tell us if you feel if you are "on track" in your
professional fellowship activities by area.
Duties
ACTUAL
Research
%
Hrs/Mo
Patient Care
%
Hrs/Mo
Professional Self-Development
%
Hrs/Mo
Education (Teaching)
%
Hrs/Mo
Administration (see note)
%
Hrs/Mo
Service/Citizenship (see note)
%
Hrs/Mo
TOTAL DUTIES
100%
Hrs/Mo
IDEAL
%
%
%
%
%
%
100%
Hrs/Mo
Hrs/Mo
Hrs/Mo
Hrs/Mo
Hrs/Mo
Hrs/Mo
Hrs/Mo
ON TRACK
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Don't Know
○ Don't Know
○ Don't Know
○ Don't Know
○ Don't Know
○ Don't Know
○ Don't Know
10. What was (were) the biggest barrier(s) to accomplishing your goals last year (be specific) and what specific
actions have you taken/plan to take? (especially if not on track in one or more areas)
11. What made your professional life more successful last year (be specific)?
12. From your experience, what would you suggest that entering fellows must know as they begin Fellowship?
13. Other comments or suggestions:
14. ABP SCHOLARLY ACTIVITY/ WORK PRODUCT ABSTRACT
Define anticipated focus area of ABP approved scholarly activity: (check main one)
○ Biomedical research (laboratory, clinical)
○ Meta-analysis of literature
○ Systematic review of clinical practice (rigor of Cochrane review)
○ Critical analysis of public policy relevant to subspecialty
○ Curriculum development project with an assessment component
○ Other: (explain if different from currently approved ABP work products)
Anticipated work product of scholarly activity (to be submitted as part of ABP subspecialty certification on
completion of fellowship)
○ Peer reviewed publication
○ Manuscript (in-depth) describing completed project
○ Thesis or dissertation written in connection with the pursuit of advanced degree
○ Extramural grant application that has either been accepted or favorably reviewed
○ Progress report for projects of exceptional complexity, such as a multi-year clinical trial
ABSTRACT (describe fellowship scholarly activity project-limit 250 words-must be completed)
Title of project:
Scholarly activity/work product mentor(s):
Background:
Question/hypothesis:
Design/method:
Summary of activities to date/results:
Projected work product activities/outcomes over next 12 months:
* See Directions to facilitate completing form. This completed form is required to be submitted each year of your fellowship to the
Departmental Scholarship Oversight Committee. Dates will be announced each academic calendar year for Years 1 - 3.
Any fellow who is having challenges meeting fellowship goals is encouraged to contact his/her mentors and/or division chief; if
difficulties persist, a fellow may contact Mary-Ann Shafer, Chair of the Scholarship Oversight Committee or Sam Hawgood, Chair of
Pediatrics, or any member of his/her SOC member for confidential discussion.