{"id":7067,"date":"2021-11-18T15:16:09","date_gmt":"2021-11-18T21:16:09","guid":{"rendered":"https:\/\/asmbs.org\/surgical-mentorship-program\/"},"modified":"2024-02-07T21:58:10","modified_gmt":"2024-02-08T02:58:10","slug":"surgical-mentorship-program","status":"publish","type":"page","link":"https:\/\/asmbs.org\/surgical-mentorship-program\/","title":{"rendered":"ASMBS Surgical Mentorship Program"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\">ASMBS Surgical Mentorship Program<\/h2>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-vimeo wp-block-embed-vimeo wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/831604149?h=34bcdadb69&amp;dnt=1&amp;app_id=122963\" width=\"640\" height=\"360\" frameborder=\"0\" allow=\"autoplay; fullscreen; picture-in-picture\"><\/iframe>\n<\/div><\/figure>\n\n\n\n<p>Need help navigating a balance between work and home? Feeling burned out in your career? Want advice on how to navigate administration or evolve your practice? Want to advance in your academic career? Or are you someone with some experience or knowledge to advise a less experienced surgeon?<\/p>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-layout-1 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<figure class=\"wp-block-image\"><img loading=\"lazy\" decoding=\"async\" width=\"493\" height=\"225\" src=\"https:\/\/asmbs.org\/wp-content\/uploads\/2021\/11\/ASMBS_Mentor_Logo2021.png\" alt=\"\" class=\"wp-image-12897\" srcset=\"https:\/\/asmbs.org\/wp-content\/uploads\/2021\/11\/ASMBS_Mentor_Logo2021.png 493w, https:\/\/asmbs.org\/wp-content\/uploads\/2021\/11\/ASMBS_Mentor_Logo2021-300x137.png 300w\" sizes=\"(max-width: 493px) 100vw, 493px\" \/><\/figure>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<p>On behalf of the Diversity and Inclusion committee, we present the <strong>ASMBS Surgical Mentorship Program<\/strong> to help promote professional success, reduce burnout, and encourage the well-being of our surgeons. Pairing an early career with mid-career surgeons (5-15 years of practice) and mid-career with senior surgeons (&gt;15 years of experience\/retired) will target the needs of the mentee over 1 year. Apply today to become a mentee or a mentor!<\/p>\n<\/div>\n<\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h4 class=\"wp-block-heading\" style=\"margin-top:0;margin-right:0;margin-bottom:0;margin-left:0;padding-top:0;padding-right:0;padding-bottom:0;padding-left:0\">Testimonials<\/h4>\n\n\n\n<div style=\"height:14px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-layout-2 wp-block-columns-is-layout-flex\" style=\"margin-top:0;margin-bottom:0;padding-top:0;padding-right:0;padding-bottom:0;padding-left:0\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<figure class=\"wp-block-embed is-type-video is-provider-vimeo wp-block-embed-vimeo wp-embed-aspect-4-3 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/910524023?h=b22f3e7b18&amp;dnt=1&amp;app_id=122963\" width=\"640\" height=\"480\" frameborder=\"0\" allow=\"autoplay; fullscreen; picture-in-picture\"><\/iframe>\n<\/div><\/figure>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\n<figure class=\"wp-block-embed is-type-video is-provider-vimeo wp-block-embed-vimeo wp-embed-aspect-4-3 wp-has-aspect-ratio\" style=\"margin-top:0;margin-right:0;margin-bottom:0;margin-left:0\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" src=\"https:\/\/player.vimeo.com\/video\/910524223?h=52973e4579&amp;dnt=1&amp;app_id=122963\" width=\"640\" height=\"480\" frameborder=\"0\" allow=\"autoplay; fullscreen; picture-in-picture\"><\/iframe>\n<\/div><\/figure>\n<\/div>\n<\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h3 class=\"wp-block-heading\">Mission<\/h3>\n\n\n<span class=\"wp-core-block wp-block-list\">\n<ul>\n<li>To provide a mentorship program that aims to promote surgeons\u2019 career professional and personal success.<\/li>\n\n\n\n<li>To reduce burnout of surgeons and encourage the well-being of ASMBS bariatric surgeons.<\/li>\n\n\n\n<li>To provide mentorship to encourage involvement within ASMBS society and future leadership roles.<\/li>\n<\/ul>\n<\/span>\n\n\n<h3 class=\"wp-block-heading\">Who is eligible?<\/h3>\n\n\n<span class=\"wp-core-block wp-block-list\">\n<ul>\n<li>Surgeons who are members in good standing of ASMBS, with either active or retired practices in the United States.<\/li>\n\n\n\n<li>Residents and current fellows are encouraged to apply when they are active in practice.<\/li>\n\n\n\n<li>An early-career surgeon (less than 5 years of experience in bariatric surgery) in the mentee role will be paired with a mentor of a mid-career bariatric surgeon (5-15 years of experience).<\/li>\n\n\n\n<li>A mid-career bariatric surgeon (5-15 years experience in bariatric surgery) in the role of mentee will be paired with a mentor of a senior bariatric surgeon (&gt;15 years of experience or retiree).<\/li>\n\n\n\n<li>Preference for mentoring spots will be given to FASMBS members and surgeons with an ASMBS fellowship certificate.<\/li>\n\n\n\n<li><strong>Less experienced or first-time mentors are encouraged to apply; mentor resources will be provided to help guide your experience!<\/strong><\/li>\n<\/ul>\n<\/span>\n\n\n<h3 class=\"wp-block-heading\">Requirements to Mentorship Program<\/h3>\n\n\n\n<p>1-year commitment, at minimum quarterly meetings (4x a year). Matches will be paired yearly. Mentees and mentors must complete surveys at the mid-year and end of the year.<\/p>\n\n\n\n<p>Once accepted, mentees must submit a worksheet describing short- and long-term goals and a self-assessment plan to the mentor within 30 days of pairing notification. Mentors will initiate contact within 15 days to set up the first visit via telephone or videoconference. At the conclusion of each meeting, future meeting times should be scheduled, and the mentor should propose a specific action plan for the mentee to work on.<\/p>\n\n\n\n<p>Pairings will be performed based on selected interests, with a preference for mentoring spots given to FASMBS members and ASMBS fellowship certificate holders. At any time, the mentee and\/or mentor may request a change in pairings after an appropriate trial period or in rare events of severe incompatibility with follow-up from the program leadership. Pairings will be based on availability and sufficient compatibility. If new pairings are requested during the last quarter of the mentorship cycle, reapplication will be required for the next cycle.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Application<\/h3>\n\n\n\n<p>The next cycle of applications will start on February 5, 2024, and close on March 11, 2024.<\/p>\n\n\n\n<p>If you were a previous mentor applicant, please notify Jennifer to bypass this application.<\/p>\n\n\n\n<p>Please contact <a href=\"mailto:jennifer@asmbs.org\">jennifer@asmbs.org<\/a> for assistance.<\/p>\n\n\n<script type=\"text\/javascript\">var 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enctype='multipart\/form-data'  id='gform_76'  action='\/wp-json\/wp\/v2\/pages\/7067' data-formid='76' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_76' class='gform_fields top_label form_sublabel_below description_above'><fieldset id=\"field_76_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_44\" ><legend class='gfield_label gform-field-label' >I&#039;m a prospective...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_76_44'>\n\t\t\t<div class='gchoice gchoice_76_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Mentee'  id='choice_76_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_44_0' id='label_76_44_0' class='gform-field-label gform-field-label--type-inline'>Mentee<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Mentor'  id='choice_76_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_44_1' id='label_76_44_1' class='gform-field-label gform-field-label--type-inline'>Mentor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_45\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_hidden\"  data-js-reload=\"field_76_45\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><h3 class=\"gsection_title\">Application<\/h3><\/div><fieldset id=\"field_76_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_76_1'>\n                            \n                            <span id='input_76_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_76_1_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_76_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_76_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_76_1_6' value=''   aria-required='true'   placeholder='Last Name'  \/>\n                                                    <label for='input_76_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_76_3\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_3\" ><label class='gfield_label gform-field-label' for='input_76_3'>ASMBS Member ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_76_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_76_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_4\" ><legend class='gfield_label gform-field-label' >Are you a Fellow of ASMBS (FASMBS) or have you received a Fellowship Certificate from ASMBS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_76_4'>\n\t\t\t<div class='gchoice gchoice_76_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' 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gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_76_5_container'>\n                                <span id='input_76_5_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_5' id='input_76_5' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_76_5' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_76_5_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_5_2' id='input_76_5_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_76_5_2' 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gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_7\" ><label class='gfield_label gform-field-label' for='input_76_7'>Current Institution\/Hospital<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_76_7' type='text' value='' class='large'    placeholder='Institution Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_76_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_8\" ><legend class='gfield_label gform-field-label' >Years in practice?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_76_8'>\n\t\t\t<div class='gchoice gchoice_76_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Less than 5 years'  id='choice_76_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_8_0' id='label_76_8_0' class='gform-field-label gform-field-label--type-inline'>Less than 5 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='5-15 years'  id='choice_76_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_8_1' id='label_76_8_1' class='gform-field-label gform-field-label--type-inline'>5-15 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='&gt;15 years or retired'  id='choice_76_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_8_2' id='label_76_8_2' class='gform-field-label gform-field-label--type-inline'>&gt;15 years or retired<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_76_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_9\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What is your current type of practice?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_9'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_9'><div class='gchoice gchoice_76_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Academic'  id='choice_76_9_1'   aria-describedby=\"gfield_description_76_9\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_9_1' id='label_76_9_1' class='gform-field-label gform-field-label--type-inline'>Academic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Academic Affiliated'  id='choice_76_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_9_2' id='label_76_9_2' class='gform-field-label gform-field-label--type-inline'>Academic Affiliated<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Community Practice\/Hospital Employed'  id='choice_76_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_9_3' id='label_76_9_3' class='gform-field-label gform-field-label--type-inline'>Community Practice\/Hospital Employed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Private Practice'  id='choice_76_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_9_4' id='label_76_9_4' class='gform-field-label gform-field-label--type-inline'>Private Practice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Rural'  id='choice_76_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_9_5' id='label_76_9_5' class='gform-field-label gform-field-label--type-inline'>Rural<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Military'  id='choice_76_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_9_6' id='label_76_9_6' class='gform-field-label gform-field-label--type-inline'>Military<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Government (non-military)'  id='choice_76_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_9_7' id='label_76_9_7' class='gform-field-label gform-field-label--type-inline'>Government (non-military)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_76_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_10\" ><legend class='gfield_label gform-field-label' >What best describes your gender?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_76_10'>\n\t\t\t<div class='gchoice gchoice_76_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Female'  id='choice_76_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_10_0' id='label_76_10_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Male'  id='choice_76_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_10_1' id='label_76_10_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Non-binary\/third gender'  id='choice_76_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_10_2' id='label_76_10_2' class='gform-field-label gform-field-label--type-inline'>Non-binary\/third gender<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_10_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Prefer not to say'  id='choice_76_10_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_10_3' id='label_76_10_3' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_10_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Prefer to self-describe'  id='choice_76_10_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_10_4' id='label_76_10_4' class='gform-field-label gform-field-label--type-inline'>Prefer to self-describe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_10_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Transgender'  id='choice_76_10_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_10_5' id='label_76_10_5' class='gform-field-label gform-field-label--type-inline'>Transgender<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_76_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_11\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which racial group do you identify with?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_11'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_11'><div class='gchoice gchoice_76_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='South Asian'  id='choice_76_11_1'   aria-describedby=\"gfield_description_76_11\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_1' id='label_76_11_1' class='gform-field-label gform-field-label--type-inline'>South Asian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='East Asian'  id='choice_76_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_2' id='label_76_11_2' class='gform-field-label gform-field-label--type-inline'>East Asian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Black, African, African American, or Afro-Caribbean'  id='choice_76_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_3' id='label_76_11_3' class='gform-field-label gform-field-label--type-inline'>Black, African, African American, or Afro-Caribbean<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Middle Eastern or North African'  id='choice_76_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_4' id='label_76_11_4' class='gform-field-label gform-field-label--type-inline'>Middle Eastern or North African<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='Native American or American Indian'  id='choice_76_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_5' id='label_76_11_5' class='gform-field-label gform-field-label--type-inline'>Native American or American Indian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.6' type='checkbox'  value='Native Hawaiian\/ other Pacific Islander'  id='choice_76_11_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_6' id='label_76_11_6' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian\/ other Pacific Islander<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_11_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.7' type='checkbox'  value='White'  id='choice_76_11_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_7' id='label_76_11_7' class='gform-field-label gform-field-label--type-inline'>White<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_11_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.8' type='checkbox'  value='Other (describe)'  id='choice_76_11_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_8' id='label_76_11_8' class='gform-field-label gform-field-label--type-inline'>Other (describe)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_11_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.9' type='checkbox'  value='Prefer not to answer'  id='choice_76_11_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_11_9' id='label_76_11_9' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_12\" ><label class='gfield_label gform-field-label' for='input_76_12'>Other Race<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_76_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_76_71\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_71\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Which ethnic group do you identify with?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_71'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_71'><div class='gchoice gchoice_76_71_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.1' type='checkbox'  value='Hispanic\/Latinx'  id='choice_76_71_1'   aria-describedby=\"gfield_description_76_71\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_71_1' id='label_76_71_1' class='gform-field-label gform-field-label--type-inline'>Hispanic\/Latinx<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_71_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.2' type='checkbox'  value='Non-Hispanic\/Latinx'  id='choice_76_71_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_71_2' id='label_76_71_2' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic\/Latinx<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_71_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.3' type='checkbox'  value='Other'  id='choice_76_71_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_71_3' id='label_76_71_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_71_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.4' type='checkbox'  value='Prefer not to answer'  id='choice_76_71_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_71_4' id='label_76_71_4' class='gform-field-label gform-field-label--type-inline'>Prefer not to answer<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_79\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_79\" ><label class='gfield_label gform-field-label' for='input_76_79'>Other Ethnic Group<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_76_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_76_13\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_13\" ><hr>\n<b>Please select focused interests for the mentoring year. This will help us match you with a well-suited mentor.<\/b><\/div><div id=\"field_76_46\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_46\" ><hr>\n<b>Please select areas of expertise you feel you can best support in a mentee with these particular interests.<\/b><\/div><fieldset id=\"field_76_72\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_76_72\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Select your top 2 interests<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_72'><div class='gchoice gchoice_76_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Leadership Growth'  id='choice_76_72_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_72_1' id='label_76_72_1' class='gform-field-label gform-field-label--type-inline'>Leadership Growth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='Practice Growth'  id='choice_76_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_72_2' id='label_76_72_2' class='gform-field-label gform-field-label--type-inline'>Practice Growth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_72_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.3' type='checkbox'  value='Research Growth'  id='choice_76_72_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_72_3' id='label_76_72_3' class='gform-field-label gform-field-label--type-inline'>Research Growth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_72_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.4' type='checkbox'  value='Personal Growth'  id='choice_76_72_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_72_4' id='label_76_72_4' class='gform-field-label gform-field-label--type-inline'>Personal Growth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_72_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.5' type='checkbox'  value='Engagement, Inclusion and Diversity Support'  id='choice_76_72_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_72_5' id='label_76_72_5' class='gform-field-label gform-field-label--type-inline'>Engagement, Inclusion and Diversity Support<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_73\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_73\" ><p><b>For those interests above, please select the top 2 interests within each category.<\/b><\/p><\/div><div id=\"field_76_82\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_82\" ><p><b>For the interests selected above, please select the top 2 options for mentoring a mentee with these areas of development.<\/b><\/p><\/div><fieldset id=\"field_76_74\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_76_74\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Leadership Growth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_74'>Select your top 2 interests.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_74'><div class='gchoice gchoice_76_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Executive Coaching'  id='choice_76_74_1'   aria-describedby=\"gfield_description_76_74\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_74_1' id='label_76_74_1' class='gform-field-label gform-field-label--type-inline'>Executive Coaching<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Hospital Leadership'  id='choice_76_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_74_2' id='label_76_74_2' class='gform-field-label gform-field-label--type-inline'>Hospital Leadership<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_74_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.3' type='checkbox'  value='ASMBS Leadership Growth'  id='choice_76_74_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_74_3' id='label_76_74_3' class='gform-field-label gform-field-label--type-inline'>ASMBS Leadership Growth<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_74_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.4' type='checkbox'  value='Building a Cooperative Environment in OR\/Practice'  id='choice_76_74_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_74_4' id='label_76_74_4' class='gform-field-label gform-field-label--type-inline'>Building a Cooperative Environment in OR\/Practice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_74_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.5' type='checkbox'  value='Conflict Resolution with Staff and\/or Colleagues'  id='choice_76_74_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_74_5' id='label_76_74_5' class='gform-field-label gform-field-label--type-inline'>Conflict Resolution with Staff and\/or Colleagues<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_74_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.6' type='checkbox'  value='Other:'  id='choice_76_74_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_74_6' id='label_76_74_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_15\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_15\" ><label class='gfield_label gform-field-label' for='input_76_15'>Other Leadership<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_76_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_76_75\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_76_75\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Practice Growth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_75'>Select your top 2 interests.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_75'><div class='gchoice gchoice_76_75_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.1' type='checkbox'  value='Private Practice Development'  id='choice_76_75_1'   aria-describedby=\"gfield_description_76_75\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_75_1' id='label_76_75_1' class='gform-field-label gform-field-label--type-inline'>Private Practice Development<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_75_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.2' type='checkbox'  value='Rural Practice Development'  id='choice_76_75_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_75_2' id='label_76_75_2' class='gform-field-label gform-field-label--type-inline'>Rural Practice Development<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_75_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.3' type='checkbox'  value='Developing an MBSAQIP Program'  id='choice_76_75_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_75_3' id='label_76_75_3' class='gform-field-label gform-field-label--type-inline'>Developing an MBSAQIP Program<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_75_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.4' type='checkbox'  value='Contract Negotiations'  id='choice_76_75_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_75_4' id='label_76_75_4' class='gform-field-label gform-field-label--type-inline'>Contract Negotiations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_75_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.5' type='checkbox'  value='Other'  id='choice_76_75_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_75_5' id='label_76_75_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_17\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_17\" ><label class='gfield_label gform-field-label' for='input_76_17'>Other Practice Growth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_76_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_76_76\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_76_76\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Research Growth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_76'>Select your top 2 interests.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_76'><div class='gchoice gchoice_76_76_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.1' type='checkbox'  value='Academic Promotion'  id='choice_76_76_1'   aria-describedby=\"gfield_description_76_76\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_76_1' id='label_76_76_1' class='gform-field-label gform-field-label--type-inline'>Academic Promotion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_76_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.2' type='checkbox'  value='Research Guidance'  id='choice_76_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_76_2' id='label_76_76_2' class='gform-field-label gform-field-label--type-inline'>Research Guidance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_76_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.3' type='checkbox'  value='Grant Writing'  id='choice_76_76_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_76_3' id='label_76_76_3' class='gform-field-label gform-field-label--type-inline'>Grant Writing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_76_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.4' type='checkbox'  value='Other'  id='choice_76_76_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_76_4' id='label_76_76_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_19\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_19\" ><label class='gfield_label gform-field-label' for='input_76_19'>Other Research Growth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_76_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_76_77\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_76_77\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Personal Growth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_77'>Select your top 2 interests.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_77'><div class='gchoice gchoice_76_77_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.1' type='checkbox'  value='Work-life Balance'  id='choice_76_77_1'   aria-describedby=\"gfield_description_76_77\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_77_1' id='label_76_77_1' class='gform-field-label gform-field-label--type-inline'>Work-life Balance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_77_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.2' type='checkbox'  value='Work-family Balance'  id='choice_76_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_77_2' id='label_76_77_2' class='gform-field-label gform-field-label--type-inline'>Work-family Balance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_77_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.3' type='checkbox'  value='Work-family Balance with Young Children'  id='choice_76_77_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_77_3' id='label_76_77_3' class='gform-field-label gform-field-label--type-inline'>Work-family Balance with Young Children<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_77_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.4' type='checkbox'  value='Other'  id='choice_76_77_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_77_4' id='label_76_77_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_21\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_21\" ><label class='gfield_label gform-field-label' for='input_76_21'>Other Personal Growth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_76_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_76_78\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_76_78\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Engagement, Inclusion and Diversity Support<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_78'>Select your top 2 interests.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_78'><div class='gchoice gchoice_76_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Addressing Microaggressions\/Implicit Bias at Workplace'  id='choice_76_78_1'   aria-describedby=\"gfield_description_76_78\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_78_1' id='label_76_78_1' class='gform-field-label gform-field-label--type-inline'>Addressing Microaggressions\/Implicit Bias at Workplace<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Overcoming Imposter Syndrome'  id='choice_76_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_78_2' id='label_76_78_2' class='gform-field-label gform-field-label--type-inline'>Overcoming Imposter Syndrome<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_78_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.3' type='checkbox'  value='Addressing Burnout'  id='choice_76_78_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_78_3' id='label_76_78_3' class='gform-field-label gform-field-label--type-inline'>Addressing Burnout<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_78_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.4' type='checkbox'  value='Becoming an Effective Teacher to Students\/Residents\/Fellows'  id='choice_76_78_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_78_4' id='label_76_78_4' class='gform-field-label gform-field-label--type-inline'>Becoming an Effective Teacher to Students\/Residents\/Fellows<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_78_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.5' type='checkbox'  value='Other'  id='choice_76_78_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_78_5' id='label_76_78_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_23\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_23\" ><label class='gfield_label gform-field-label' for='input_76_23'>Other Engagement, Inclusion and Diversity Support<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_76_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_76_47\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_47\" ><p><b>Mentor Preferences<\/b><\/p>\n<p>Please select preferences for a mentor and we will do our best to match preferences.<\/p><\/div><div id=\"field_76_48\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_48\" ><p><b>Mentee Preferences<\/b><\/p>\n<p>Please select preferences for a mentee and we will do our best to match preferences.<\/p><\/div><fieldset id=\"field_76_24\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" data-js-reload=\"field_76_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Preferences<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_24'><div class='gchoice gchoice_76_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Academic Medicine'  id='choice_76_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_1' id='label_76_24_1' class='gform-field-label gform-field-label--type-inline'>Academic Medicine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Ethnicity\/Race Preference'  id='choice_76_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_2' id='label_76_24_2' class='gform-field-label gform-field-label--type-inline'>Ethnicity\/Race Preference<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Gender Preference'  id='choice_76_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_3' id='label_76_24_3' class='gform-field-label gform-field-label--type-inline'>Gender Preference<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='LGBTQ Preference'  id='choice_76_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_4' id='label_76_24_4' class='gform-field-label gform-field-label--type-inline'>LGBTQ Preference<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Mentor Involved in ASMBS Leadership'  id='choice_76_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_5' id='label_76_24_5' class='gform-field-label gform-field-label--type-inline'>Mentor Involved in ASMBS Leadership<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Mentor Involved with Hospital Leadership'  id='choice_76_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_6' id='label_76_24_6' class='gform-field-label gform-field-label--type-inline'>Mentor Involved with Hospital Leadership<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Military Background'  id='choice_76_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_7' id='label_76_24_7' class='gform-field-label gform-field-label--type-inline'>Military Background<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Mindfulness Towards Balancing'  id='choice_76_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_8' id='label_76_24_8' class='gform-field-label gform-field-label--type-inline'>Mindfulness Towards Balancing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Work with Families with Young Children'  id='choice_76_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_9' id='label_76_24_9' class='gform-field-label gform-field-label--type-inline'>Work with Families with Young Children<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Private Practice'  id='choice_76_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_11' id='label_76_24_11' class='gform-field-label gform-field-label--type-inline'>Private Practice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Other'  id='choice_76_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_12' id='label_76_24_12' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='No Preference'  id='choice_76_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_24_13' id='label_76_24_13' class='gform-field-label gform-field-label--type-inline'>No Preference<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_28\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_28\" ><label class='gfield_label gform-field-label' for='input_76_28'>Other Preference<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_28'>Enter your Other option for the selection above.<\/div><div class='ginput_container ginput_container_text'><input name='input_28' id='input_76_28' type='text' value='' class='large'  aria-describedby=\"gfield_description_76_28\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_76_80\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_80\" ><p><b>Select the Gender and Race\/Ethnicity Preferences in a mentor<\/b><\/p><\/div><div id=\"field_76_83\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_83\" ><p><b>Select the Gender and Race\/Ethnicity Preferences in a mentee<\/b><\/p><\/div><fieldset id=\"field_76_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_25\" ><legend class='gfield_label gform-field-label' >Gender Preference<\/legend><div class='gfield_description' id='gfield_description_76_25'>Select a preference for your above ranking.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_76_25'>\n\t\t\t<div class='gchoice gchoice_76_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Female'  id='choice_76_25_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_76_25\"   \/>\n\t\t\t\t\t<label for='choice_76_25_0' id='label_76_25_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Male'  id='choice_76_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_25_1' id='label_76_25_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Non-binary'  id='choice_76_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_25_2' id='label_76_25_2' class='gform-field-label gform-field-label--type-inline'>Non-binary<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_76_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No preference'  id='choice_76_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_76_25_3' id='label_76_25_3' class='gform-field-label gform-field-label--type-inline'>No preference<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_76_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_26\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Race \/ Ethnicity Preference<\/legend><div class='gfield_description' id='gfield_description_76_26'>Select all that apply for your above ranking.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_26'><div class='gchoice gchoice_76_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Non-Hispanic White or Caucasian'  id='choice_76_26_1'   aria-describedby=\"gfield_description_76_26\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_76_26_1' id='label_76_26_1' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic White or Caucasian<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Non-Hispanic Black or African American'  id='choice_76_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_26_2' id='label_76_26_2' class='gform-field-label gform-field-label--type-inline'>Non-Hispanic Black or African American<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Hispanic\/Latino\/a\/Latinx'  id='choice_76_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_26_3' id='label_76_26_3' class='gform-field-label gform-field-label--type-inline'>Hispanic\/Latino\/a\/Latinx<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='American Indian or Alaska Native.'  id='choice_76_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_26_4' id='label_76_26_4' class='gform-field-label gform-field-label--type-inline'>American Indian or Alaska Native.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='Asian American and Pacific Islanders'  id='choice_76_26_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_26_5' id='label_76_26_5' class='gform-field-label gform-field-label--type-inline'>Asian American and Pacific Islanders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='No Preference'  id='choice_76_26_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_26_6' id='label_76_26_6' class='gform-field-label gform-field-label--type-inline'>No Preference<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_76_26_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.7' type='checkbox'  value='Other (describe)'  id='choice_76_26_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_76_26_7' id='label_76_26_7' class='gform-field-label gform-field-label--type-inline'>Other (describe)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_76_27\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_27\" ><label class='gfield_label gform-field-label' for='input_76_27'>Other Race \/ Ethnicity Preference<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_27'>Enter a preference for your above ranking.<\/div><div class='ginput_container ginput_container_text'><input name='input_27' id='input_76_27' type='text' value='' class='large'  aria-describedby=\"gfield_description_76_27\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_76_30\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_30\" ><b>Please answer the following questions:<\/b><\/div><div id=\"field_76_31\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_31\" ><label class='gfield_label gform-field-label' for='input_76_31'>How would you describe yourself?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_31'>1-2 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_76_31' class='textarea large'  aria-describedby=\"gfield_description_76_31\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_32\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_32\" ><label class='gfield_label gform-field-label' for='input_76_32'>What assets, skills or experiences are you most proud of?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_32'>2-3 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_76_32' class='textarea large'  aria-describedby=\"gfield_description_76_32\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_33\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_33\" ><label class='gfield_label gform-field-label' for='input_76_33'>What are the three most important goals you hope to achieve in the next 12 months-2 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_33'>3-4 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_76_33' class='textarea large'  aria-describedby=\"gfield_description_76_33\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_34\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_34\" ><label class='gfield_label gform-field-label' for='input_76_34'>Identify the key elements needed to achieve this goal in general.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_34'>2-3 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_76_34' class='textarea large'  aria-describedby=\"gfield_description_76_34\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_35\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_35\" ><label class='gfield_label gform-field-label' for='input_76_35'>Are there weaknesses in training, skills, or experience that will impede your success?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_35'>1-2 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_76_35' class='textarea large'  aria-describedby=\"gfield_description_76_35\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_36\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_36\" ><label class='gfield_label gform-field-label' for='input_76_36'>Are you currently facing any issues which are hindering your career development?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_36'>1-2 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_76_36' class='textarea large'  aria-describedby=\"gfield_description_76_36\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_37\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_37\" ><label class='gfield_label gform-field-label' for='input_76_37'>What aspects of work do you find challenging that make you feel drained or stressed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_37'><p>e.g teaching residents or medical students, time management, running late in the OR.<br>\n1-3 sentences.<p><\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_76_37' class='textarea large'  aria-describedby=\"gfield_description_76_37\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_81\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_81\" ><label class='gfield_label gform-field-label' for='input_76_81'>What aspects of work are you most of proud of and gives you the most joy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_81'>2-3 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_81' id='input_76_81' class='textarea large'  aria-describedby=\"gfield_description_76_81\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_38\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_38\" ><label class='gfield_label gform-field-label' for='input_76_38'>Have you had a mentor before? If so, what has contributed to a successful or challenging mentor-mentee relationship?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_38'>1-3 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_38' id='input_76_38' class='textarea large'  aria-describedby=\"gfield_description_76_38\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_39\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_39\" ><label class='gfield_label gform-field-label' for='input_76_39'>What are the top three things you need from your mentor to be successful?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_76_39' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_49\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_49\" ><label class='gfield_label gform-field-label' for='input_76_49'>What skills, knowledge and insights do you have that would be valuable sharing with your mentee?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_76_49' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_53\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_53\" ><label class='gfield_label gform-field-label' for='input_76_53'>What are you hoping to learn or achieve as a result of this mentoring experience?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_53'>2-3 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_76_53' class='textarea large'  aria-describedby=\"gfield_description_76_53\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_54\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_54\" ><label class='gfield_label gform-field-label' for='input_76_54'>Have you been a mentor before? If so, what has contributed to a successful or challenging mentor-mentee relationship?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_54'>1-3 sentences.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_76_54' class='textarea large'  aria-describedby=\"gfield_description_76_54\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_50\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_50\" ><label class='gfield_label gform-field-label' for='input_76_50'>What are the top three things you need from your mentee to be successful?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_76_50' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_76_65\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_65\" ><label class='gfield_label gform-field-label' for='input_76_65'>Are you willing to take on a second mentee?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_65' id='input_76_65' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_76_66\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_66\" ><label class='gfield_label gform-field-label' for='input_76_66'>Will you commit to initiating contact with your mentee within 2 weeks of application pairing?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_76_66' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_76_41\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_41\" ><label class='gfield_label gform-field-label' for='input_76_41'>Will you commit to meeting (at minimum) quarterly with your mentor\/mentee, completing a mid-year and end of the year short survey, and submitting an action plan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_76_41'>Failure to do so may result in early termination from the mentoring program.<\/div><div class='ginput_container ginput_container_select'><select name='input_41' id='input_76_41' class='large gfield_select'  aria-describedby=\"gfield_description_76_41\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><fieldset id=\"field_76_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_76_40\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >What methods of communication best fit your style to communicate with your mentor\/mentee?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_76_40'>Select all that apply.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_76_40'><div class='gchoice gchoice_76_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Phone Calls'  id='choice_76_40_1'   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Feeling burned out in your career? Want advice on how to navigate administration or evolve your practice? Want to advance in your academic career? Or are you someone with some experience or knowledge to advise a less experienced surgeon? On behalf of <a class=\"more-link\" href=\"https:\/\/asmbs.org\/surgical-mentorship-program\/\">Read more&#8230;<\/a><\/p>\n","protected":false},"author":11114,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[357],"tags":[],"audience":[389],"content-format":[],"acf":[],"_links":{"self":[{"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/pages\/7067"}],"collection":[{"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/users\/11114"}],"replies":[{"embeddable":true,"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/comments?post=7067"}],"version-history":[{"count":14,"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/pages\/7067\/revisions"}],"predecessor-version":[{"id":19109,"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/pages\/7067\/revisions\/19109"}],"wp:attachment":[{"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/media?parent=7067"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/categories?post=7067"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/tags?post=7067"},{"taxonomy":"audience","embeddable":true,"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/audience?post=7067"},{"taxonomy":"content-format","embeddable":true,"href":"https:\/\/asmbs.org\/wp-json\/wp\/v2\/content-format?post=7067"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}