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SIMS Physician Mentor Form, 2019-2020
Thank you for your interest in the SIMS Program. Please fill out the form below if you would like to serve as a physician mentor for the 2019-2020 academic year.
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Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
Department/Specialty
*
Your answer
With more clinics moving to off-campus sites, transportation may become an issue for some of our students. Where do you anticipate the shadowing sessions taking place? (e.g. Lucile Packard Children's Hospital)
*
Your answer
Will it be possible for students to shadow you on campus (SHC, LPCH, local clinics,)?
*
Yes
No
Other:
Availability
*
Days of the week (AM for morning availability, PM for afternoon availability
Monday (AM)
Monday (PM)
Tuesday (AM)
Tuesday (PM)
Wednesday (AM)
Wednesday (PM)
Thursday (AM)
Thursday (PM)
Friday (AM)
Friday (PM)
Weekends (AM)
Weekends (PM)
Other (Please explain in the following question)
Required
Anything else you would like the students to know (e.g. specialty, training, hobbies, etc.)?
Your answer
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