MS PHD'S: Mentor Application

Institute for Broadening Participation: Building Partnerships to Support Diversity in STEM

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MS PHD'S Mentor Application
It is recommended that you prepare responses to these questions in a text editor such as notepad and copy and paste your responses in the required field

Personal Information

First Name

Last Name

Institution/Agency

Position

Contact Information

Address Line 1

Address Line 2 (optional)

City State Zip

Country

Phone Area Code 7 Digit Number
( )
Email

Homepage (optional)

Background Information

Citizenship
United States Citizen
Non-U.S. Citizen, Permanent U.S. Resident Visa ^*
Non-U.S. Citizen ^*
Non-U.S. Citizen, Temporary U.S. Resident Visa ^*

* If not a U.S. Citizen, of what country are you a resident?

Gender
Male Female

Race/Ethnicity (optional)
African American
Other Hispanic American
Mexican American/Chicano
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Puerto Rican
Asian
Caucasian/White
Decline to Answer

Highest Degree Received
M.S. Ph.D.
Year in which you received your highest degree (e.g. 2004)

Academic Preparation

Academic Discipline
** Please specify if you select the option

Discipline
Atmospheric Science/Meteorology
Engineering**     Please specify:
Environmental Science
Geography
Geology/Geophysics
Geomagnetism/Paleomagnetism
Hydrology
Limnology
Oceanography/Marine Science
Paleoceanography/Paleoclimatology
Science Education
Space Physics/Aeronomy/Planetary Science
Volcanology/Geochemistry/Petrology
Technology^**    Please specify:
Other^**     Please specify

Environmental Specialty
Atmosphere
Coastal Ocean/Estuaries/Marine Wetlands
Deep Ocean
Freshwater Wetlands
Groundwater/ Subsurface water
Lakes and Reservoirs
Open Ocean
Rivers and Streams
Space
Other^**    Please specify

Disciplinary Specialty

Biological
Chemical
Geological
Mathematics
Modeling^**    Please specify
Physical
Technology Application/ Development ^**    Please specify
Other^**    Please specify

Research Interests
(max 100 words)

Past research areas and topics

Current research areas and topics

Future research areas and topics

Biographical and Research Summary

If you participated in other programs designed to increase diversity in STEM fields, please list name(s) and contact information for each program in which you participated.

Program 1
Program Name:

Program Contact Person:

Website address:

Phone number:

Email address:

Program 2
Program Name:

Program Contact Person:

Website address:

Phone number:

Email address:

Program 3
Program Name:

Program Contact Person:

Website address:

Phone number:
Phone number:
Email address:

Program 4
Program Name:

Program Contact Person:

Website address:

Phone Number:

Email address:

Hobbies/interests (optional)

Mentor Experience

Did you have a mentor during your undergraduate/graduate school experience?
yes no

If you did not have a mentor, was it by choice or due to the absence of an appropriate individual who was willing to serve in this capacity?
by choice due to absence

If so, what was the most important benefit you received? (optional)

Have you participated in the MSPHD'S previously?
yes no

Have you participated in any diversity training program?
yes no

Professional Experience & Affilations

Mentor Commitment of Service

I am willing to provide the following services to MSPHD'S in Earth participants. (Please check all that apply)
1. Networking assistance
2. Scientific research advice
3. Career advice
4. Career advancement assistance
5. Assistance in comprehending academic courses
6. Educational opportunities
7. Other
8. Other

Mentor Commitment of Time

I am willing to interact with my mentee face-to-face, by phone or through the virtual community:
1. Weekly
2. Bi-weekly
3. Monthly
4. Other

Mentor Expectations of Mentee

Select at least three commitments that you expect your mentee to make to support the success of your partnership

1. Promptness in response
2. Follow-through on assigned tasks
3. Professionalism/commitment to quality work
4. Engagement in discussion
5. Other
6. Other

Outcomes

List at least one short term and one long term indicator of success that you will look for to justify your investment of resources and time as a mentor.
(max 100 words)

1. Short Term

2. Long Term

Preferred Mentee

We would appreciate your input regarding mentor-mentee assignments. Please review the MS PHD'S Participants' profiles and submit the three possible names of your preferred mentee. Efforts will be made to accommodate your stated preferences.

Mentee 1

Mentee 2

Mentee 3

Please be patient and hit the submit button only once.
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