Date:________________
Name:_______________________________ Title:__________________________
Performance:__________________________ to ______________________________
1. What are your professional development needs to assure that you stay current with and/or advance in your profession i.e., seminars, workshops, on-and/or off-campus conference, committee and/or task force assignments, new work assignments, mentors, etc?
2. What committee and/or task force assignments would assist and assure your continued professional development?
3. Would you like to participate in a mentor program? If so, would you like to have a mentor assigned or would you like to choose your own mentor?
Yes, I would like to participate in a mentor program.
Yes, I would like to have a mentor assigned to me.
No, I have chosen_________________________as a mentor.
The outcomes I would hope to achieve by participating in a mentor program are:
4. I would like to attend the following seminars, workshops, on-campus and/or off-campus conferences to continue my professional development. (Note: List your needs in the order of priority. Departmental funding and scheduling will be considered when reviewing applications. When determining the estimated cost, please include expenses for registration fee, travel, lodging, the daily per diem allowed, and miscellaneous expenses.)
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