⏱ Please set aside about 30 minutes to complete this application. Need a break? Click Save & Return Later at the bottom of any page. Write down the return code you are given; you can come back and pick up where you left off.Once you click Submit, your application is final and cannot be reopened or changed.
This single form is used by both prospective mentees and prospective mentors. Completing it does not guarantee a place in the program; the Office of Clinical Research reviews every application and will follow up.
OCR use: Email this applicant automatically when a decision (Approved, Waitlisted, Denied) is saved?
Yes
No
Set to Yes automatically for every new applicant. Change to No only to skip decision emails for this person.
OCR use: Application process version (2 = October 2026 combined application)
Filled in automatically for new applicants. Blank = applied under the earlier process. Used so Module 1 only sends under the new process.
I consent to having my de-identified responses used for program evaluation and research, including possible publication in aggregate form. (You may apply either way, but consent allows your data to support evaluation of the program.)
* must provide value
Yes
No
Date and time you are giving consent (24-hour format)
* must provide value
Now Y-M-D H:M Enter the date and time you are completing this consent. Format: YYYY-MM-DD HH:MM (24-hour). You may use the current date and time.
First Name
* must provide value
Last Name
* must provide value
Email (must be a @utsouthwestern.edu address)
* must provide value
Please use your UT Southwestern email address.
Do you have a preferred name or nickname? (leave blank if none)
Department
* must provide value
Internal Medicine Surgery Pediatrics Psychiatry Neurology Radiology Pathology Obstetrics & Gynecology Anesthesiology Dermatology Ophthalmology Orthopaedic Surgery Otolaryngology Urology Emergency Medicine Family & Community Medicine Physical Medicine & Rehabilitation Radiation Oncology Simmons Comprehensive Cancer Center Cardiology Oncology / Hematology Population & Data Sciences Clinical Sciences Neurosurgery Other
Please specify your department:
* must provide value
Have you applied to this mentoring program before?
* must provide value
No - this is my first time applying
Yes - I applied for a previous cohort
Yes - I am reapplying after a previous cohort
No - this is my first time applying
Yes - I applied for a previous cohort
Yes - I am reapplying after a previous cohort
If you applied before, we welcome your reapplication.
If you applied before, which cohort or approximate date?
Are you applying as a mentee or a mentor?
* must provide value
Mentee
Mentor
Mentee = you are seeking a mentor. Mentor = you are offering to mentor someone else.
My current role
* must provide value
Clinical Research Assistant I Clinical Research Assistant II Clinical Research Assistant Lead Clinical Research Coordinator I Clinical Research Coordinator II Clinical Research Coordinator Lead Supervisor Clinical Research Manager Clinical Research Manager Research Programs Project Manager Clinical Research Research RN Research RN Senior Supervisor Research Nurse Manager Research Nurse Advanced Practice Research Nurse Other
Please specify your role:
* must provide value
How long have you been in your current role? (round down)
* must provide value
Less than 1 month
1 to 2 months
3 months
4 months
5+ months
Less than 1 month
1 to 2 months
3 months
4 months
5+ months
Have you had any previous clinical research experience before your current role?
* must provide value
Yes
No
How many years of combined research experience did you have previously, NOT including your current role?
* must provide value
Less than 1 year
1-2 years
3-4 years
5+ years
Less than 1 year
1-2 years
3-4 years
5+ years
Have you ever completed formal clinical research training at another institution prior to UT Southwestern?
* must provide value
Yes
No
Have you been a mentor or a mentee in the past?
* must provide value
Yes - I have been a mentee
Yes - I have been a mentor
Yes - both a mentor and a mentee
This is my first mentoring program experience
Yes - I have been a mentee
Yes - I have been a mentor
Yes - both a mentor and a mentee
This is my first mentoring program experience
Have you taken the Clinical Research Foundations training in CITI?
* must provide value
Yes - I have started it
Yes - I have completed it
No
Yes - I have started it
Yes - I have completed it
No
Approximate date you started the CITI course
Today Y-M-D
Approximate date you completed the CITI course
Today Y-M-D
Please check off all the types of study designs currently assigned to you:
* must provide value
Please indicate if your role requires any of the following specialized tasks:
* must provide value
Please describe the other specialized task(s):
* must provide value
Tell us about yourself - hobbies, interests (short bio):
* must provide value
Please share your top 3 workplace values, in order of priority:
* must provide value
What characteristics are most important to you in a mentor match?
* must provide value
In a few sentences, why do you want to join the program? What do you hope to gain?
* must provide value
What specific skills or goals do you most want to work on with a mentor?
* must provide value
I attest that, if accepted, I am able to commit to meeting with my mentor at least every 2-3 weeks for 3-4 months and to completing all six modules.
* must provide value
Yes
No
Name of your direct supervisor
* must provide value
Is your direct supervisor aware of and supportive of your participation?
* must provide value
Yes
No
Direct supervisor's email (must be a UTSW @utsouthwestern.edu address)
* must provide value
Your supervisor must be a UT Southwestern employee. After you submit, an endorsement survey will be emailed to this address asking them to verify their support of your participation.
Your role relative to this supervisor
* must provide value
Direct report Coordinator on their team Research staff they oversee Trainee / fellow they supervise Other
Please specify your role relative to this supervisor:
* must provide value
OPTIONAL: Anything else you would like the review committee to know?
My current role
* must provide value
Clinical Research Assistant I Clinical Research Assistant II Clinical Research Assistant Lead Clinical Research Coordinator I Clinical Research Coordinator II Clinical Research Coordinator Lead Supervisor Clinical Research Manager Clinical Research Manager Research Programs Project Manager Clinical Research Research RN Research RN Senior Supervisor Research Nurse Manager Research Nurse Advanced Practice Research Nurse Other
Please specify your role:
* must provide value
Besides your current department, what other departments have you worked in at UT Southwestern? (Please list; if none, write None.)
* must provide value
What other specialties or areas of clinical research have you worked in?
* must provide value
Have you been a mentor or a mentee in the past?
* must provide value
Yes - I have been a mentee
Yes - I have been a mentor
Yes - both a mentor and a mentee
This is my first experience
Yes - I have been a mentee
Yes - I have been a mentor
Yes - both a mentor and a mentee
This is my first experience
How many years of combined clinical research experience do you have (include other institutions)?
* must provide value
Less than 2 years
2-3 years
3+ years
Less than 2 years
2-3 years
3+ years
Have you completed the Clinical Research Foundations CITI course?
* must provide value
Yes
No
Please check off all the study designs your department is currently overseeing:
* must provide value
If you have experience in specific study designs in the past but not now, please indicate:
* must provide value
Please specify the other study design(s):
* must provide value
Please indicate if you have experience working in any of the following:
Please specify the other area(s) of experience:
* must provide value
Please indicate any patient-facing or clinical-workflow experience you have:
* must provide value
OPTIONAL: What do you anticipate being your biggest challenge or barrier to overcome as a mentor?
OPTIONAL: What do you hope to take away from your mentorship experience?
OPTIONAL: Any other information that would assist us with making a match?
Below, rank the top 3 qualities you value most in a mentee (1 = most important).
Choice 1
* must provide value
Open approach to learning Prepared for meetings Willingness to ask for help Willingness to accept constructive feedback Proactive Takes responsibility for one's own actions Arrives on time for meetings Respectful Grateful/humble Honest/transparent
Choice 2
* must provide value
Open approach to learning Prepared for meetings Willingness to ask for help Willingness to accept constructive feedback Proactive Takes responsibility for one's own actions Arrives on time for meetings Respectful Grateful/humble Honest/transparent
Choice 3
* must provide value
Open approach to learning Prepared for meetings Willingness to ask for help Willingness to accept constructive feedback Proactive Takes responsibility for one's own actions Arrives on time for meetings Respectful Grateful/humble Honest/transparent
I attest that, if approved, I am able to commit to the mentorship program for the full duration (meeting with my mentee at least every 2-3 weeks for 3-4 months across 6 modules).
* must provide value
Yes
No
If approved, how many mentees are you able to take on this cohort?
* must provide value
One
Two
The program pairs each mentor with up to two mentees.
Your answers place you into one of four mentoring styles so the Office of Clinical Research can pair you with a strong-fit partner. There are no right or wrong answers; answer for how you actually work best.
What do you most want to get out of this program?
* must provide value
Master concrete skills and learn how to do the day-to-day work well (A)
Understand the big picture and figure out my career direction (B)
Build confidence, belonging, and a professional network (C)
Get pointed in the right direction so I can run with things on my own (D)
Master concrete skills and learn how to do the day-to-day work well (A)
Understand the big picture and figure out my career direction (B)
Build confidence, belonging, and a professional network (C)
Get pointed in the right direction so I can run with things on my own (D)
Which best describes the research focus you want to grow in?
* must provide value
Hands-on study operations and procedures (A)
Study design, strategy, and the why behind the science (B)
Working with people, teams, and participants (C)
Independently managing my own studies or tasks (D)
Hands-on study operations and procedures (A)
Study design, strategy, and the why behind the science (B)
Working with people, teams, and participants (C)
Independently managing my own studies or tasks (D)
How do you learn best?
* must provide value
By doing it hands-on with someone showing me each step (A)
By discussing, questioning, and thinking it through out loud (B)
By being encouraged and watching someone model it first (C)
By figuring it out myself with resources to fall back on (D)
By doing it hands-on with someone showing me each step (A)
By discussing, questioning, and thinking it through out loud (B)
By being encouraged and watching someone model it first (C)
By figuring it out myself with resources to fall back on (D)
What kind of feedback helps you most?
* must provide value
Specific, corrective, in-the-moment on the task (A)
Reflective questions that make me think (B)
Warm, affirming, focused on encouragement (C)
Brief and only when I ask for it (D)
Specific, corrective, in-the-moment on the task (A)
Reflective questions that make me think (B)
Warm, affirming, focused on encouragement (C)
Brief and only when I ask for it (D)
What kind of mentor would suit you best?
* must provide value
Directive and structured, gives me clear steps (A)
A sounding board who advises and challenges me (B)
Supportive and patient, builds me up (C)
Hands-off, gives me autonomy and resources (D)
Directive and structured, gives me clear steps (A)
A sounding board who advises and challenges me (B)
Supportive and patient, builds me up (C)
Hands-off, gives me autonomy and resources (D)
Your ideal mentor relationship feels like:
* must provide value
A trainer walking me through the work (A)
A strategist helping me see the path (B)
A cheerleader who has my back (C)
A consultant I check in with occasionally (D)
A trainer walking me through the work (A)
A strategist helping me see the path (B)
A cheerleader who has my back (C)
A consultant I check in with occasionally (D)
What do you most enjoy offering as a mentor?
* must provide value
Teaching concrete skills and how to do the work well (A)
Sharing big-picture perspective and career guidance (B)
Building a mentee's confidence, belonging, and network (C)
Pointing a capable mentee in the right direction and letting them run (D)
Teaching concrete skills and how to do the work well (A)
Sharing big-picture perspective and career guidance (B)
Building a mentee's confidence, belonging, and network (C)
Pointing a capable mentee in the right direction and letting them run (D)
Where is your strength as a mentor?
* must provide value
Hands-on study operations and procedures (A)
Study design, strategy, and scientific reasoning (B)
People, teams, and participant-facing work (C)
Helping others become independent operators (D)
Hands-on study operations and procedures (A)
Study design, strategy, and scientific reasoning (B)
People, teams, and participant-facing work (C)
Helping others become independent operators (D)
How would you describe your teaching style?
* must provide value
I demonstrate and walk mentees through each step (A)
I ask questions and let mentees reason it out (B)
I encourage, model, and reassure (C)
I give direction and resources, then step back (D)
I demonstrate and walk mentees through each step (A)
I ask questions and let mentees reason it out (B)
I encourage, model, and reassure (C)
I give direction and resources, then step back (D)
How do you tend to give feedback?
* must provide value
Specific and corrective, in the moment (A)
Through reflective questions (B)
Warm and affirming (C)
Briefly, and mostly when asked (D)
Specific and corrective, in the moment (A)
Through reflective questions (B)
Warm and affirming (C)
Briefly, and mostly when asked (D)
Which mentee do you work best with?
* must provide value
One who wants clear structure and hands-on training (A)
One who wants a sounding board to think with (B)
One who needs encouragement and confidence-building (C)
One who wants autonomy and light-touch guidance (D)
One who wants clear structure and hands-on training (A)
One who wants a sounding board to think with (B)
One who needs encouragement and confidence-building (C)
One who wants autonomy and light-touch guidance (D)
Your ideal mentoring relationship feels like:
* must provide value
A trainer developing a skill set (A)
A strategist shaping a path (B)
A supporter building someone up (C)
A consultant checking in periodically (D)
A trainer developing a skill set (A)
A strategist shaping a path (B)
A supporter building someone up (C)
A consultant checking in periodically (D)
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Match group letter (A/B/C/D)
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The four mentee styles
A - The Builder: You want concrete skills and hands-on mastery. You learn best by doing, with someone showing you each step. You thrive with a directive, structured mentor.
B - The Navigator: You want the big picture and career direction. You learn by discussing and questioning. You thrive with a mentor who acts as a sounding board and challenges your thinking.
C - The Connector: You want confidence, belonging, and a network. You learn through encouragement and seeing things modeled. You thrive with a supportive, patient mentor.
D - The Independent: You want autonomy with light guidance. You learn by figuring things out yourself. You thrive with a hands-off mentor who points you toward resources and lets you run.
The four mentor styles
A - The Coach: You offer structured skill-building and close guidance. You teach by demonstrating and walking mentees through the work. You pair best with Builders.
B - The Advisor: You offer career perspective and strategic questioning. You teach by asking and challenging. You pair best with Navigators.
C - The Encourager: You offer support and confidence-building. You teach by affirming and modeling, with patience. You pair best with Connectors.
D - The Delegator: You offer autonomy, resources, and light oversight. You point mentees in the right direction and step back. You pair best with Independents.
You have reached the end. Please review your answers before you click Submit . After you submit, you will not be able to return to or change this application. The Office of Clinical Research will review your application and contact you. Questions? Email OCR@utsouthwestern.edu.
Mentee: letter of support received and reviewed?
Yes
No
SUPERVISOR ENDORSEMENT STATUS (updated from the supervisor's linked endorsement survey).
Has the supervisor endorsement been received for this applicant?
Yes
No
Set to Yes once the linked Supervisor Endorsement survey is submitted. Leave No while pending - this drives the incomplete flag.
⚠ ENDORSEMENT NOT YET RECEIVED - this application is INCOMPLETE. Do not approve until the supervisor endorsement is on file, or record an explicit override reason below.
✓ Supervisor endorsement received and on file. Application is complete for review.
Supervisor endorsement outcome (copy from the linked endorsement record)
Endorsed
Endorsed with reservations
Not endorsed
Not yet received
Endorsed
Endorsed with reservations
Not endorsed
Not yet received
⚠ You are approving an applicant whose supervisor endorsement is not yet on file. This is allowed, but please record why below.
Override reason (required if approving a mentee without endorsement on file)
Approved
Waitlisted - review for next cohort
Denied
Pending review
Approved
Waitlisted - review for next cohort
Denied
Pending review
Approved, Waitlisted and Denied each email the applicant when you save, if "Email this applicant automatically" (top of this form) is Yes.
Today Y-M-D
Reviewer name (OCR staff)
If denied or waitlisted, reason / notes (internal)
AUTO-GENERATED FOR ENROLLMENT. These values fill in automatically when you save this form and are copied into the Enrollment form.
View equation Format UTSW-MTE-#### (mentee) or UTSW-MTR-#### (mentor). Number = this record ID.
Dyad ID (auto, mentees only)
View equation Mentors don't get their own dyad ID; they take their mentee's.
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Supervisor first name (auto)
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Supervisor last name (auto)
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Submit
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