OBGYN Mentor Questionnaire | Department of Obstetrics & Gynaecology

OBGYN Mentor Questionnaire

Thank you for your interest in being part of the department-wide mentorship program. In order to have you matched with a mentee please take a couple of minutes to complete this questionnaire.

This information will be held in a secure web page that is password protected and without a parent page (that means you can’t just surf to it but must be given the URL).

If you have any questions please direct them amartin2@providencehealth.bc.ca.

OBGYN Mentor Biography

Please select the option that best describes you:*
- Clinical Educator
- Clinical Scientist
- Scientist
Name*
Preferred Email Address*
Preferred Phone Number*
Gender
- Male
- Female
- Do not wish to disclose
Years in practice*
Cultural of origin/background
Family status (married, single, children, furbies)*
Please describe your current research activities (if applicable)
Please describe your administrative roles (if applicable)
Briefly tell us about yourself. What you like to do outside of work? What gets you excited about life?*
What are the three words you would use to describe yourself?*
Why do you want to be a mentor?*
Is there anything else we should know about you that will help you to be matched with a mentee?*
What are a few of your expectations from the program?*