Impact of Professional Coaching: Interest Form

Please complete the survey below if you are interested in enrolling in the Impact of Professional Coaching study.

We are examining the impact of professional coaching on early career academic emergency physician well-being, burnout, leadership strengths, goal attainment, and adult level of development.

We use dynamic randomization to choose participants. Completing this survey does not ensure enrollment into the study.

If you are chosen to participate, you will be contacted by Emergency Medicine Research at Mayo Clinic.

This research study is funded by the James H. and Helen F. Crossingham Emergency Medicine Award and enrollees are required to pay $250 prior to coaching to help cover costs of coaching and assessments.

Thank you!

First Name

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Last Name

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Gender

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Institution

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Email Address

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Academic Rank

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Instructor

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Academic Rank "Other"

The Informed Consent Form (ICF) is available below for you to download. Print and read the ICF and contact us with any questions by either:
• calling 507-255-9353,
• or by emailing RSTEMERGENCYDEPTRES@mayo.edu.

After you have read through the consent and all your questions have been answered, please sign and date the ICF.

Attachment:16.01019200 Informed Consent IRB approved (2018-03-12).pdf

Once you have signed and dated the ICF, please attach it here.

Please do NOT electronically sign the ICF, per Mayo Clinic IRB requirements.

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Once we receive your signed consent, a Mayo Clinic study team member will contact you with the next steps.

If, in two weeks, the Mayo Clinic study team has not heard from you, we will contact you with a reminder email. If we do not hear from you a week after the reminder email, we will remove you from the list of interested participants.

Research-related questions or any research-related complaints may be addressed to RSTEMERGENCYDEPTRES@mayo.edu. If you prefer to speak with someone independent of the research team, you may contact the Mayo Institutional Review Board (IRB) (contact information listed on the second page of the Informed Consent).

Thank you very much for your time and consideration.

Sincerely,

Mayo Clinic, Rochester Emergency Department Research Team on behalf of Principal Investigator, Richard Winters, MD, MBA, Emergency Medicine Consultant.

Emergency Department Research
Phone: 507-255-9353| Fax: 507-255-7939 | E-mail: RSTEMERGENCYDEPTRES@mayo.edu
Mayo Clinic | 200 First Street SW | Rochester, MN 55905 | www.mayoclinic.org

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