Subject Matter Expert EnrollmentSubject Matter Expert Enrollment FormSubject Matter Expert Enrollment FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Program *Diarrheal Disease ECHORoad to Success in Residency- 2025Which aspect of the program are you interested in participating in? You can choose more than one (find about each aspect in the post above) *Virtual sessionsMentorshipObservershipFirst Name *This is how it will appear on the announcementsLast Name *This is how it will appear on the announcementsEmail Address *WhatsApp *Preferred Mode of Communication *EmailWhatsAppBoth Email or WhatsAppLinkedin Link or work webpage *type “no” if not availableTwitter handle *type “no” if not availableLocation *USInternationalAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAddress *Address Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryName of Institution/Hospital/University *Choose one affiliation to be included in the announcementsPosition/Academic Rank *Choose one rank (e.g. Professor or consultant—not both)Speciality/Subspeciality *City/State *Country *Biosketch *In less than 250 words Professional Photo * Click or drag a file to this area to upload. .png, .jpg, .jpeg format; shows the face and shoulders; shows the face and shoulders, square shape, professional background; this picture will be posted on the website CV * Click or drag a file to this area to upload. .pdf, .doc, .docx format; Mentorship programPreferred Mentorship Duration *3 months6 months12 monthsHow many mentees are you willing to accept at a time (up to three) *Preferred Mentorship Type *1:1 MentorshipGroup Mentorship (up to 5 mentees)Both works for meDo you have any criteria or preferences for mentees (e.g., level, gender preference)? *Observership programPreferred Observership Duration (as minimum as half a day) *When is the start date for accepting observers? *When is the end date for accepting observers? *Do you have any criteria or preferences for observers (e.g., level, gender preference)? *Please indicate your preference regarding the background check for observers *Background check is not required.My institution will conduct the background check.I request SAMA to conduct the background check on my behalf.Are you currently involved in any other mentorship/observership program? *YesNoDiarrheal Disease ECHO SessionTopics/dates (you can choose more than one) *March 15, 2025 Oral Rehydration Therapy (ORT) – Best PracticesApril 5, 2025 Community Engagement – Educating Patients and FamiliesApril 12, 2025 Infection Prevention and Control MeasuresApril 19, 2025 Managing Complications and Severe CasesVirtual sessionsTopics/dates (you can choose more than one) *Writing CV- Saturday, February 1, 2025Personal statement-Saturday, Saturday, February 15, 2025Letter of Recommendation, March 1, 2025Choosing the right residency program -Saturday, March 29, 2025Internal medicine match application- Saturday, April 12, 2025Surgery match application- Saturday, April 26, 2025Neurology match application-Saturday, May 10, 2025Understanding Match and Application Timelines: Step-by-step guidance on ERAS, NRMP-Saturday, June 21, 2025Thriving in Your Intern Year: Maintaining Work-Life Balance During Residency, Understanding your paycheck, getting you finances right- Saturday, July 5, 2025Visa application process: Maintaining visa status during residency. Understanding immigration pathways (e.g., J1 waiver, H1B, green card).-Saturday, July 19, 2025Interview preparation-Saturday, August 2, 2025Ranking of programs- Saturday, August 16, 2025SAMA Values and non-discrimination policy. *I agree to abide by the SAMA Values and the program’s non-discrimination policy.probono *I understand that I am volunteering my time and will not be paid for this learning activityAttestation of SME Responsibilities *I attest to reading the SME Responsibilities outlined by the Facilitator and will abide with themSlide Preparation Use the slide template provided by the facilitator (that contains the relevant logos) Do not include any patient personal information (e.g. name, date of birth, medical record number) Day of Session Join 15 minutes before the session starts to confirm everything is in working order Use a quiet location with stable, high-speed internet Please use a computer that has a camera Position the webcam so the whole face is visibleIn the event of unforeseen unavailability, i.e. unable to present with less than one month notice *I give permission to a colleague to present my slides on my behalfConsent to record presentation and share with learners *I gave permission to record my talk and share with learnersConsent to share pdf of presentation with learners *I gave permission to share the pdf of my talk with the learnersConsent to include content of my presentation in SAMA Learning Management System (Moodle) *I gave permission to content of my presentation in SAMA Learning Management System (Moodle)Responsiveness Commitment *I understand that I have to respond within one week to select a mentee/observer once their information is made available.I understand that I have to contact the selected mentee/observer within one month of their selection to initiate the observership/mentorship process.Submit form
