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State Epidemiologist Mentorship Interest Survey

The information gathered on this form will only be used to help match you with a mentor and to ensure the Foundation has your correct contact information.

Contact Information

Name

First Name

Last Name

Verify Email

I am interested in being matched with a mentor from the 1951 Society

YES

My Employer

Work Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

How long have you held your position as the "State Epidemiologist"?

How many years of total experience as an Applied Epidemiologist do you have?

Areas of Interest

Are there one or more areas in which you need mentorship or support? Check next to any topic that would be a priority for you in matching you with a mentor.

General Management

Staff Management

Managing "Up"

Communications

Epidemiology Speciality Infectious, Chronic, Environmental... Tell us more in the Other box below

Other

Area of Interest - Other

If you answered "Epidemiology Specialty" or "Other" in the previous question, tell us more about your needs here.