SOCIETY FOR EXPERIMENTAL BIOLOGY & MEDICINE (SEBM)

Young Scientist Mentoring Program

Mentor/Mentee Questionnaire/Application Form for 2009 Awards

Personal Information

Name:                                                            Degree:                   

Salutation:            Dr.            Prof.            Mr.            Ms.

Phone:                             E-mail:                                                              

Address:                                                                                       

Profile:

1.   Mentor        Mentee

2.   Gender (optional):  Male        Female

3.   Ethnic Group (optional):                                                             

4.   Area of Major Interest:

           Basic Research
           Translational Research
           Clinical Research

5.   Academic Rank:

           Graduate Student
           Postdoctoral Fellow
           Clinical Fellow
           Assistant Professor
           Associate Professor
           Professor
           Other:                                                

6.   Research Area (Multidisciplinary Categories):

           Anatomy/Pathology
           Biochemistry/Molecular Biology
           Cell and Developmental Biology
           Endocrinology
           Gastroenterology
           Immunology
           Microbiology
           Neuroscience
           Nutrition
           Pharmacology/Toxicology
           Physiology
           Virology
           Other:                                                

Basic Research Area (Interdisciplinary Categories):

           Bioimaging
           Biomedical Engineering
           Bionanoscience
           Bioinformatics
           Genomics
           Proteomics
           Stem Cell Biology
           System Biology
           Translational Research
           Other:                                                

7.   Research Clinical Area:

           Medicine
           Endocrinology
           Dermatology
           Gastroenterology
           Neurology
           Cardiology
           Pulmonology
           Immunology
           Rheumatology
           Oncology
           Geriatrics
           Rehabilitative Medicine
           Other:                                                
           Obstetrics/Gynecology/Reproductive Health
           Other:                                                   
           Pediatrics
           Neonatology
           Adolescent Medicine
           General Pediatrics
           Other:                                                
           Radiology
           Other:                                                
           Psychology/Psychiatry
           Other:                                                

8.   Areas of Interest for Mentoring:

           Career Advancement
           Grantmanship
           Enhancing Professional Visibility
           Entry to Research in Industry
           Methodological Approaches
           Networking with Other Scientists
           Publishing
           Research Focus
           Teaching
           Other:                                                

9.   Membership Affiliation (Check all that apply):
           SEBM            AAA            APS            ASBMB
           ASIP            ASIP            ASN            ASPET
           Other:                                                  

10. Match Preference if Possible (Optional):
           Female            Male             Ethnic group

11. Do You Have a Request for a Potential Mentor?
           Yes            No

If Yes, Please Provide:
Name:                                                                                              
University Affiliation:                                                                      
Department:                                                                                   
Mailing Address:                                                                             
Phone:                                      Fax:                                     
E-mail:                                                                                             

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