1 Agreement Form

OMB # 0925-0748
Expiration Date: 8/2023
Network of Minority Health Research Investigators (NMRI) Mentorship Agreement Form
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this b
urden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0748). Do not return
the completed form to this address.

Network of Minority Research Investigators (NMRI)
Mentorship Agreement Form
Part I:
Submit this section to Winnie.Martinez@nih.gov right after establishing the Mentor-Mentee relationship.
Note: The NMRI Oversight Committee recognizes the importance of a positive Mentor-Mentee relationship for
any successful career advancement in academic medicine. This Mentorship Agreement Form has been designed
to guide and improve the Mentor-Mentee relationship and assist the Oversight Committee in evaluating the
progress of this relationship. As such it would be very helpful to us if the Mentees and/or Mentors would kindly
provide any feedback on this form or ways one may improve it.
Mentee:
Name: __________________________________ Email: __________________________________
I will actively search and identify a Mentor from the Network of Minority Research Investigators. I understand
that it is my responsibility to contact and identify the willingness of this investigator in serving as my mentor. To
this end I will secure her/his signature and I agree to contact her/him at least on a quarterly basis.
Mentor:
Name: _________________________________ Email: __________________________________
I have agreed to serve as a mentor to the above investigator. I will be available for at least four annual
communications and to provide constructive feedback for the above stated educational and/or scientific
objectives.
Timeline for Contacting Mentor: Schedule dates for e-mail, phone or in-person contact.
Quarterly Contact with NMRI Mentee

Date of Contact with Mentee

Spring 201___
Summer 201___
Fall 201___
Winter 201___
Educational objective: note: please select as many as you and your mentor are willing to work on:
A. Refine skills required to submit manuscript, grant, or dossier
B. Refine or construct a research question or hypothesis
C. Refine skills necessary to select the appropriate statistic, set up a data base and/or perform data
analysis
D. Others (please list):
___________________________________________________________________________________________
Signed:

Mentee ____________________________ Mentor _____________________________
Date:

________________

Date:

________________

NIH NMRI Mentorship Agreement Revised 05-17-2016

Network of Minority Research Investigators (NMRI)
Mentorship Agreement Form

Mentee:

Mentor:

Part 2 (for the Mentee):
Submit this section to Winnie.Martinez@nih.gov prior to the Annual Meeting in April, the year after the
agreement was signed. Please answer the following questions:
1.

Did you contact your mentor quarterly? (Select one)
YES
NO

2.

Which of the following objectives were met? (Select all that apply):
A. Refine skills required to submit manuscript, grant, or dossier
B. Refine or construct a research question or hypothesis
C. Refine skills necessary to select the appropriate statistic, set up a data base and perform data analysis
D. Others (please list):

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
3.

Which of the following objectives were not met? (Select all that apply):
A. Refine skills required to submit manuscript, grant, or dossier
B. Refine or construct a research question or hypothesis
C. Refine skills necessary to select the appropriate statistic, set up a data base and perform data analysis
D. Others (please list):

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
4.

Did this mentee/mentor relationship facilitate your progress?
Strongly Agree
1

5.

2

Disagree
3

Strongly Disagree
4

Did this mentee/mentor relationship hinder your progress?
Strongly Agree
1

6.

Agree

Agree
2

Disagree
3

Strongly Disagree
4

How could the NMRI mentee/mentor relationship be improved?

___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________________________________
NIH NMRI Mentorship Agreement Revised 05-17-2016

OMB # 0925-0748
Expiration Date: 2/2023
Network of Minority Health Research Investigators (NMRI) Request a Mentor Form
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0748). Do not return
the completed form to this address.

Network of Minority Research Investigators (NMRI)
Request a Mentor Form
If you are interested in becoming a mentee of the NMRI, please complete the following form and send a
copy via email to: Winnie.Martinez@nih.gov. This information will be forwarded to NIDDK staff and the
NMRI Oversight Committee to determine if there is someone who would like to be your mentor.
Name:

Degree(s):

Title:
Organization:
Address:
City:

State:

Zip Code:

Email Address:
Telephone:

Fax:

1. Are you currently a member of the NMRI? _______ If not, you must join the NMRI in order to request a
mentor. Go to https://forms.niddk.nih.gov/nmri/Membership.aspx and complete the membership request
form.
2. Indicate your current status:
Senior Investigator

Junior Investigator

Fellow

Post Doc

Student

3. List your areas of research interest. Please list at least 3 areas and prioritize them from 1-3.
1. ________________________________
2. ________________________________
3. ________________________________
4. If you have suggestions for a mentor, please list them in the space below.
___________________________________________________________________
Please save this file and email it to Winnie.Martinez@nih.gov.
NIH NMRI Mentor Agreement Revised 05-17-2016

OMB # 0925-0748
Expiration Date: 2/2023
Network of Minority Health Research Investigators (NMRI) Request a Mentee Form
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0748).
Do not return the completed form to this address.

Network of Minority Research Investigators (NMRI)
Request a Mentee Form
If you are interested in becoming a mentor of the NMRI, please complete the following form and send a
copy via email to: Winnie.Martinez@nih.gov. This information will be forwarded to NIDDK staff and
the NMRI Oversight Committee to determine if there is someone who may qualify to be your mentee.
Name:

Degree(s):

Title:
Organization:
Address:
City:

State: _

Zip Code:

Email Address:
Telephone:

Fax:

1. How long have you been a member of the NMRI? _______
2. Indicate your current status:

Senior Investigator

Junior Investigator

Fellow

Post Doc

Student

3. List your areas of research interest. Please list at least 3 areas and prioritize them from 1-3.

1. ________________________________
2. ________________________________
3. ________________________________

4. If you have suggestions for a mentee, please list them in the space below.

___________________________________________________________________
Please save this file and email it to Winnie.Martinez@nih.gov.
NIH NMRI Request a Mentee Form Revised 05-17-2016