IN LSAMP Mentor Information

This form captures the demographic and training information for each IN LSAMP summer research mentor. Mentor training is a required component of the National Science Foundation award. By providing your information you assist us in maintaining accurate records. Thank you for your time.

List the names of all IN LSAMP Summer Scholars you are mentoring or have mentored in the past.

If you have not mentored a student enter N/A.

Name of summer scholar

I. MENTOR INFORMATION

Last Name*

Email*

This email will be used to send surveys and correspondence from NSF and external evaluator.

Institution*

Select

If OTHER institution, please explain:

Discipline*

Select

If OTHER discipline, please explain:

Faculty Rank*

Select or enter value

II. MENTOR TRAINING

A condition of funding through the National Science Foundation is research mentors must receive mentor training before advising/mentoring IN LSAMP undergraduate scholars. A training module was provided by IN LSAMP. After you have complete training, provide the required information below to confirm training.

Have you completed the Faculty Mentor training provided by IN LSAMP?*

Yes

Date Mentor Training Completed

Have you completed the CITI Responsible Conduct of Research Certificate?*

RCR certificates can be completed or downloaded at this website: https://research.iu.edu/training/citi/index.html

Select or enter value

If yes, upload CITI Responsible Conduct of Research certificate here.

Please upload the RCR completion certificate PDF only.

Drag and drop files here or

III. ADDITIONAL MENTOR INFORMATION

Graduate Research Assistant*

Will a graduate research assistant serve as a mentor to IN LSAMP students working in your lab? Please indicate below if the student will receive mentoring support from a graduate research assistant in your lab. If the graduate student will be serve as the primary mentor or provide partial support, we will contact them directly to obtain their demographic information.

Yes

Graduate Research Assistant Name

Graduate Research Assistant Email

IV. DEMOGRAPHIC INFORMATION

In an effort to track the diversity of our mentors, we are seeking a voluntary response to the following inquires.

Gender

Male

Female

Prefer not to respond

Ethnicity

Hispanic or Latino

NOT Hispanic or Latino

Prefer not to respond

Race

American Indian

Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Prefer not to respond

V. SIGNATURE

Signature acts as confirmation of completion of the required IN LSAMP mentor training.

Electronic Signature*

Date*

Send me a copy of my responses

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