THIMA Mentor Program Application

Mentor Program Application
Application Type *
Preferred Method of Communication

Professional Information

Credentials
Years in HIM profession
What is the highest level of education you have completed?

Employment Information

Current Students:
New Graduates, New Professionals, and Experienced Professionals:
Employment Status

Mentee Status


Mentee Status

Please specify your preference for Type of Mentee (Select Top 3)

Mentee Status *

Mentoring Information

How many years of experience do you have in the healthcare industry?
How many years of experience do you have in a professional working environment, (i.e. clerical, administrative, financial, accounting, information technology, Customer Service, Communications).
What area of healthcare is your experience? (Select all that apply)
What area of of HIM are you interested in learning more about? (Select all that apply)
Select Topics Below *
What benefits are important to you as a mentor? (Select all that apply)
What benefits are important to you as a mentee?
What information or training do you feel would be useful as a Mentor? (Select all that apply)
What resources do you think would be useful as a Mentor?
Rate the qualities that are most important to you for your Mentor to possess.

1 - Most Important, 5 - Least Important

What skills outside of the HIM domain would you like to have additional support in?
What method(s) of communication would you like to receive from your Mentor?