CAPA Mentorship Program: Mentor Questionnaire

First Name *

Last Name *

Email *

Phone *

City *

Professional Designation *

Enter required value PA-C PA PA-S MD DO FNP FNP-C PharmD Pre-PA

PA Program *

Enter required value A.T. Still University California Baptist University Central Coast Chapman University Charles R. Drew University CSU Monterey Bay Dominican University Keck Graduate Institute Loma Linda University Marshall B. Ketchum University Point Loma Nazarene University Samuel Merritt University Southern California University of Health Sciences Stanford University Touro University – California Touro University - Los Angeles Touro University Nevada University of California-Davis University of California-San Diego University of LaVerne University of Southern California University of the Pacific Western University of Health Sciences Other

If you selected other, please list the program

Graduation Date *

Preferred Meeting Times *

Please check all that apply

Mornings (before noon)

Lunch time (between 12 - 3pm)

Evenings (after 5 pm)

Weekends (Saturday or Sunday)

No preference

Preferred Method of Communication *

Please check all that apply.

E-mail

Phone (text included)

Zoom or Teams

In-person

How frequently would you like to meet with your mentee? *

Please select all that apply.

Weekly

Biweekly

Monthly

As needed

Do you prefer an early career PA, recent graduate, or current PA student to mentor? *

Please check all that apply.

No preference

Early career PA (less than 5 years)

Recent graduate (not licensed)

Current PA Student

Are there any personal values or characteristics that are important to you in a mentee?

What area of health do you practice in? *

General/Family Medicine

Primary Care

Internal Medicine

Emergency Medicine

Surgical Subspecialty

Other

If other, describe

Personal Statement

Please briefly tell us about yourself, past professional experiences, and personal interests.