Faculty Mentor Online Application

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":

Are you a member of an underrepresented group (URG) in biomedical, clinical, behavioral or social science? are unsure if you would be considered as being a part of an Underrepresented Group, see below link for a full list. This is not an exhaustive list and we are continuously working to update it accordingly to be representative of all people in underrepresented groups.

Yes
No

https://diversity.nih.gov/about-us/population-underrepresented

Please specify

Individual from racial and ethnic groups that have been shown by the National Science Foundation to be underrepresented in health-related sciences on a national basis
Individual with disabilities, who are defined as those with a physical or mental impairment that substantially limits one or more major life activities
Individual from disadvantaged backgrounds (those who meet two or more of the disadvantaged background criteria listed on the above NIH website)
Prefer not to specify

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:

24th 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