MMSAP Mentor Volunteer Form

Please fill out all fields relevant to your participation as a Minority Medical Student Award Program (MMSAP) mentor.

* = Required Field

First Name:
MI:
Last Name:
Sex:
 
* Phone:
* E-Mail:

Ethnicity:

Degree(s):
If other, please specify:
Current Academic Rank:
If other, please specify:
Years at this academic rank:
Title:
Institution Name:
Institution Mailing Address:
City:
State:
Canadian Territory (if applicable):
Zip Code:
Have you previously participated in the MMSAP?
 

If so, what was your role? (check all that apply)
If other, please specify:

Which years? (check all that apply)

Select the year(s) during which you are willing to mentor trainees. (check all that apply)

Please indicate your interest in serving as one or both of the following:

Research Mentor Career Development Mentor

Clinical Interests:

Anemia Lymphoma
Aplastic Anemia/Bone Marrow Failure Multiple Myeloma
Autoimmune Disorders Myelodysplastic Syndromes
Bleeding Disorders Myeloproliferative Disorders
Bone Marrow/Stem Cell Transplantation Pediatric Hematology/Oncology
Leukemia Sickle Cell Disease
Low Platelets Counts Thrombosis and Hemostasis/Blood Clotting
Low White Blood Cell Counts Transfusion Medicine

Research Interests:

Gene Therapy and Transfer Leukocytes, Inflammation, and Immunology
Health Services and Outcomes Research Red Cell Physiology and Disorders
Hematologic Malignancy Transfusion Medicine
Hematopoiesis Transplantation Research
Hemostasis, Thrombosis, and Vascular Wall Biology

Please e-mail a copy of your current NIH bio sketch, including current research support, to awards@hematology.org.

In the event that an applicant requests to be placed with a mentor matching your area of research, you will be contacted by ASH staff to confirm your availability. Your contact information will not be released to applicants without your approval.

Research mentors are members of ASH who assume the responsibility of overseeing the participant's work and progress. As a research mentor, you are responsible for helping the applicant develop a research proposal for the application; however, please know there is no guarantee the applicant will be accepted into the program.

Once participants have been identified for the program, the Committee on Promoting Diversity assigns each participant with a career development mentor. For the purpose of this program, mentoring is defined as the process of guiding, supporting, and promoting the training and career development of others. The key roles of a mentor include, but are not limited to, providing intellectual growth and development, career development, professional guidance, advocacy, and positive role modeling. We ask that mentors maintain regular contact with mentees through a combination of email, phone, and in-person communication. Every effort will be made during the matching process to have the mentee be local; if not in the same institution, within the same city whenever possible.