NEEDS ASSESSMENT SURVEY for MENTEES
Department of Biostatistics Faculty Mentoring Program
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“The wonderful thing about life is that you cannot succeed on your own (or fail
on your own); others are essential in defining who you are.”
Geoffrey M. Bellman, Author
Getting Things Done When You Are Not In Charge
JUNIOR MEMBERS OF THE FACULTY IN THE DEPARTMENT OF BIOSTATISTICS MUST COMPLETE THIS FORM.
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:
a. Click in the grey
box to fill in your responses; or
b. Click in the dropdown box to make your selection; or
c. Click on one selection box
per question.
When you have completed the MSWORD form, please do the following:
a. “Save as” and renaming the document. For example: Mentee M McLaughlin
b. Send an email expressing your wishes to Byron Gajewski, PhD, Associate Professor and Department
Director of Faculty Development and P&T, and attach the saved application form.
Thank you.
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PART 1: Personal Information
Name:
Degree (select one) SELECT
Additional or Other Degree(s) (Please List)
My secondary faculty appointment in the department of:
Clinical Department: SELECT
Basic Science Department: SELECT
My secondary appointment is for
Division:
% of time.
Track: (click the box to select one) SELECT
Academic Rank: (click the box to select) SELECT
Title(s) other than your Academic Rank: 1.
Leadership Roles and Positions:
Years in Rank: (click the box to select) SELECT
2.
3.
4.
Current Committees & Positions:
Area(s) of Clinical Interest:
Area(s) of Research Interest:
Current Grant Support (list sources only):
Career Total Years as Faculty Anywhere: (click the box to select) SELECT
Years as KUSOM Faculty: (click the box to select) SELECT
To schedule meetings and appointments, please contact
My e-mail Address:
(name and phone number)
Office Telephone: (913) 588-
Office Fax: (913) 588-
Age:
50-59
OPTIONAL INFORMATION:
Gender (optional):
Marital Status:
Children:
M
F
Single
yes
30-39
40-49
Significant Other
no
Married
60+
Divorced/Widowed
Please list ages:
1
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Updated: 1/31/2013
NEEDS ASSESSMENT SURVEY for MENTEES
Department of Biostatistics Faculty Mentoring Program
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
PART 2: Mentoring Interest Check-list
Check your level of need 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 AREAS or DUTIES
Check one box
(listed in alphabetical order)
Academic Administration
YES
NO
Don’t Know
Advocate for career development (e.g. Career Skills)
YES
NO
Don’t Know
Advocate for personal growth
YES
NO
Don’t Know
Availability for career guidance (e.g. selecting the right track,
YES
NO
Don’t Know
Availability for guidance on research efforts
YES
NO
Don’t Know
Balancing home and family
YES
NO
Don’t Know
Balancing Personal/Professional Life
YES
NO
Don’t Know
Basic Science Research
YES
NO
Don’t Know
Budgets (e.g. creating, understanding, following)
YES
NO
Don’t Know
Clinical /Patient Care
YES
NO
Don’t Know
Clinical Administration (including staffing issues)
YES
NO
Don’t Know
Clinical Operations
YES
NO
Don’t Know
Clinical Research
YES
NO
Don’t Know
Clinical Teaching Skills
YES
NO
Don’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,
YES
NO
Don’t Know
selecting another sub-specialty)
Area of Expertise:
Desired Area of Collaboration:
Area of Expertise:
Area of Expertise:
Desired Area of Collaboration:
discussions or Administrators)
2
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Updated: 1/31/2013
NEEDS ASSESSMENT SURVEY for MENTEES
Department of Biostatistics Faculty Mentoring Program
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Curriculum Development
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 dossier
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
Graduate teaching and evaluation
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
Mission-based budgeting
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
Promotion / Tenure (including how to chose a career track)
YES
NO
Don’t Know
Publishing (e.g. manuscript review, authorship of book
YES
NO
Don’t Know
Resident teaching and evaluation
YES
NO
Don’t Know
Sharing in collegial network
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
chapters, contributions to published symposia)
3
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Updated: 1/31/2013
NEEDS ASSESSMENT SURVEY for MENTEES
Department of Biostatistics Faculty Mentoring Program
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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.
a. I made the initial contacted with my current mentor:
Yes
No
Yes
No
b. My mentor is from:
i.
KUMC
ii.
Outside KUMC (additional info optional)
2. I would feel most comfortable working with:
a.
MD
PhD
MD/PhD
b.
Clinician
Hospitalist
Basic Scientist
c.
Professor
Associate Professor
d.
Tenured
Non-tenured
e.
Same gender
f.
anyone
don’t care
Assistant Professor
don’t care
don’t care
Same race/ethnic origin
don’t care
Special needs of mine:
3. I would prefer to work with a mentor:
Weekly
monthly
quarterly
other
4. 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:
When you have completed the form, please submit the form
using one of these methods:
1. Email.
a. “Save as” using Mentor followed by your name. For example: Mentor M Gunion
b. In an email to Byron Gajewski, PhD, Professor and Department Director of Faculty Development and
P&T, attach the saved document. bgajewski@kumc.edu
2. Regular mail.
Byron Gajewski, PhD, Professor, Dept of Biostatistics, KUMC, Mail Stop 1049
4th Floor Robinson Hall, 3901 Rainbow Blvd., KC, KS 66160
Thank you.
4
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Updated: 1/31/2013