Presentation Proposal Form

MENTORING CALL INITIATIVE

Objective: To offer coaching, advice and strategies for professional success. Please plan on the length of your presentation being between 60-90 minutes, including time for questions and answers.

Contact Information

Last Name: *	First Name: *
E-mail Address:*
Office Phone Number: *
Cell:
Please list all postgraduate degrees:
Degree 1:	Degree 2:
Degree 3:	Degree 4:
Faculty/Professional Title(s) or Graduate Student Status:*
Institution:*

Presentation Information`

1. Type of Presentation:
PowerPoint (i.e.: conference presentation and/or job talk)
Dissertation
Poster Presentation
Grant Proposal
Manuscript
Promotion and Tenure (personal statement and other documentation)

Other:

2. Please indicate below if you would like to set up a teleconference or online videoconference. For videoconference, we currently use Adobe© Connect or Skype. However, please indicate below if you prefer to use an alternative system. (The NHSN National Office will try to set this up if all participants have access to appropriate equipment).

Teleconference
Videoconference - Adobe^© Connect
Videoconference - Skype

Other:

3. Goal of call/Outcomes you wish to accomplish:

4. Presentation Title:

5. Preferred Week Day and Time (note time zone required):

Day:

Monday Tuesday Wednesday Thursday Friday

Time:

9:00 to 11:00AM 11:00AM to 1:00PM
1:00 to 3:00PM 3:00PM to 5:00PM

Time Zone:

ET CT MT PT

6. Deadline for Feedback:

Week of :

7. Senior Researchers/Mentors to Invite:
(Hold down the Shift key to select more than one)

8. Colleagues/Team Members to Invite:
1^st Colleague/Team Member:
Name:
Title:
Email:
2^nd Colleague/Team Member:
Name:
Title:
Email:
3^rd Colleague/Team Member:
Name:
Title:
Email:

NB. Topics discussed on the mentoring group calls must remain confidential unless all participants on the call agree to an outreach decision.
Please verify your information for accuracy and completeness before clicking the Submit button. Upon submission, you should receive an immediate email confirmation. If you do not receive this email, please contact Jane Brooks as soon as possible at jbrooks@med.miami.edu. In order to confirm that you have read and agree to the above, please type AGREE in the box below: