Please fill out this questionnaire as thoroughly as possibly. The Hispanic Center of Excellence Mentoring Board will review your request and work to place you with the appropriate mentor(s). Starred (*) items are required. If you have any questions, please contact Norma Perez, M.D., Dr.P.H. at noaperez@utmb.edu or at 409.772.3558.

*Required

• *Name:
• *Department:
• *Email:
• *Department Chair:
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• *Position:
• Assistant Professor
  Associate Professor
  Other  
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• *Would you like to have one or more mentors through the HCOE?
• Yes
  No
  Other  
  
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• *Do you have a current mentor?
• Yes
  No
  
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• If so,
• One
  More Than One
  
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• What type of mentor are you looking for? You may check more than one. Please rank by the priority (e.g. 1 = the highest priority)

• 		1	2	3	4	5
  Clinical
  Basic science
  Translational/Clinical research
  Education
  Academic (clinical/research/educator)
  Career mentor

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• Specific areas of mentoring need (rank all that apply by number)

• 		1	2	3	4	5
  Promotion and tenure
  Scientific exchange
  Grant preparation
  Review activities (grants/ journal articles)
  Minority faculty issues

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• If another type of mentoring is needed, please explain.
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• Additional Information/Comments/Requests
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• UTMB Safe Submit

  
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