AUPN Chair-to-Chair Coaching Pairing (Mentee)

Name (First & Last) *

Institution *

Email *

Phone *

What is your institution type? (Hold ctrl to select multiple answers) *

Is your healthcare system fully academic, or a mix of private practice and academic? *

Fully (100%) Academic

Mixed

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Is your primary hospital owned by the University? *

Yes

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Number of full time primary faculty *

Does the Department include Child Neurology? *

Yes

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What issues/areas do you most want to be matched for? (Please list in order of importance) *
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What are three objectives you hope to get out of the coaching program? *
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Please name up to 2 Chairs you would welcome as a Coach.
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Please name any individuals would you prefer not to have as a Coach.
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Additional Comments (optional)
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