Faculty Mentor Application Form

Name:*

First Last

Preferred first name/nickname (as you would like it on your badge should you be accepted to the program):

Degree(s) earned (e.g., MD, MPH):*

Institutional/work email:*

Personal email:*

Preferred email for CRIT communications:*

Personal telephone:*

Residency Program Address

Residency program name:*

Specialty (i.e., internal medicine, family medicine, other - please explain):*

Total number of residents in your residency program:

Residency program address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Residency program medical school affiliation, if any:*

Write N/A if there is none.

Residency program hospital affiliation, if any:*

Write N/A if there is none.

Residency program director name:*

Residency program director email:*

Present faculty position:*

Current academic rank*

Instructor
Assistant Professor
Associate Professor
Professor
Other
None

If "Other"- please specify:

Number of years as faculty at your institution:*

Please enter a number. Junior faculty should have at least one and less than ten years of experience as faculty.

Percentage of time teaching:*

Please enter a number from 0 to 100.

Please approximate the percentage of time you spend teaching. Enter a number from 0 to 100; do not use a percent sign.

Mailing Address

Same as residency program mailing address above?*

Yes
No

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Information

Gender identity:*

If you selected "Prefer to self describe," please specify here:

Pronouns

If you selected "Prefer to self describe," please specify here:

Race/ethnicity :*

Black or African American
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other

Select all that apply.

Please describe "other":

Have you ever visited the following in a professional context? (Check all that apply.)

A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)
A substance use treatment facility only (e.g., detox, methadone maintenance)
A harm reduction program (e.g., syringe service, naloxone distribution)

Preferred T-shirt size (should you be accepted to the program):*

Faculty Mentor Questions

Name of chief resident you are applying with:*

Please give a statement of support for the chief resident you are applying with (500 words or less), including: 1) How attending the CRIT Program with your chief resident will enhance their ability to implement addiction medicine curriculum in your residency program, including completion of a Substance Use Teaching Project (developed at CRIT), and 2) how your current faculty position will enable you to add addiction medicine content into the residency program curriculum. Please copy-paste this into the box below:*

Curriculum Vitae

Please upload your curriculum vitae (CV) as a PDF here.*

Accepted file types: doc, pdf, docx, Max. file size: 100 MB.

How did you hear about the CRIT Program?*

Previous CRIT Program attendee
Faculty at my institution
Brochure or postcard advertising the program
Internet search
Email directly from the program
Other (describe below)

Please describe "other":

Please specify:

25th Annual Chief Resident Immersion Training (CRIT) Program in Addiction Medicine: FACULTY MENTOR Application

Residency Program Address

Mailing Address

Other Information

Faculty Mentor Questions

Curriculum Vitae