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2022 NSBPA PA-C and PA-S Mentor Application
Survey for prospective mentors
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* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Preferred Pronouns
*
He/him
She/her
They/them
Other:
Gender
*
Female
Male
Nonbinary
Transgender
Prefer not to say
Other:
Race
*
African American/Black
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
White
Other:
Ethnicity
*
Hispanic or Latinx
Not Hispanic or Latinx
Where do you live? (City and state)
*
Your answer
How old are you?
*
20-30
31-40
41-50
51-60
60+
Prefer not to answer
How often would you like to interact with your mentee(s)?
*
Frequent (i.e., meetings approximately monthly)
Occasionally (i.e., quarterly)
As needed or casually (i.e., able to respond to email when mentees have questions or need advice)
What is your preferred method of contact with your mentee(s)?
*
Text/phone call
Email
Zoom/other virtual option
In-person
Group text/GroupMe/WhatsApp
How many years have you been practicing?
*
0-3 years
4-7 years
8-11 years
12-15 years
15+ years
N/A - PA student
What speciality do you practice in?
*
Your answer
Do you agree with the NSBPA mission statement? If not, please explain. The mission statement can be found at
https://nsbpa.org/about.php
*
Your answer
Would you be interested in presenting a Virtual Shadowing session for the NSBPA?
*
Yes
No
Other:
What questions or concerns do you have about being a mentor for the NSBPA? We will answer questions during our webinar informational session in September.
Your answer
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