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APIC DFW Mentoring Program: Facilitate Success for Chapter Members
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First Name
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Last Name
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Email Address
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Phone Number
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Mentor Status
Mentor
Mentee
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Facility Name
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Facility Type
LTAC, teaching, specialty, etc
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Size of Facility
Number of beds
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Rural or Urban?
Rural
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How many years have you been in IP?
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Areas of expertise / interest
Mentors list your areas of expertise. Mentees list your areas of interest.
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Preferred mentor or mentee?
If you have a preferred mentor or mentee; please identify the person.
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