Mentor Application for the 2020 Mentorship Program
Apply to become a Mentor of either a resident, fellow, junior attending, junior NP, Junior PA RN, or junior pharmacist organized through the Neurocritical Care Society, Trainee Committee. We use these application responses to help match mentors to mentees with similar interests so, please be thoughtful with your responses.

Applications are due Wednesday, January 15, 2020.

Please make sure to also email a copy of your CV to ncs.rftf@gmail.com with the subject line "Mentor Application". You can also email this address if you have any questions regarding the program.

Thank you for your interest.
Email address *
Name *
Gender
Clear selection
Do you prefer to mentor a male or a female? We may not be able to accommodate this but can take it into consideration.
Clear selection
How do you prefer to be addressed?
With what institution are you associated?
Please provide your primary email. *
Please provide your secondary email. *
Please provide your phone number. ** This will not be given to your mentee. Your number will only be used by the NCS Trainee committee in case we are unable to get in touch via email. It will be up to you to decide to exchange your phone number with your mentee. *
Years of practice in NCC? *
What is your position?
Clear selection
Do you prefer a mentee from your speciality?
Clear selection
Level of trainee you are most interested in mentoring?
In which scope(s) of practice do you prefer to mentor: (rank up to 3 preferences)
1
2
3
Clinical
Research
Education
Administration
Ethics
Publishing
Guidelines
Outreach
Clear selection
In a few sentences, please elaborate in your choices above, including any specific interests that you have within neurocritical care
The mentorship program is designed to be project oriented. Describe/Name 2 potential projects you feel would be feasible and beneficial to both yourself and your mentee to complete over the course of 1 year. (e.g. write a review paper/ case report/ book chapter, original research, design a residents neurocritical care curriculum, write a grant...)
We proved monthly emails with suggested discussion topics. Some examples from pervious years include, work-life balance, establishing yourself as a leader within your team, conflict resolution, CV assistance, salary negotiation. Do you have any topics that you think would be helpful for early career guidance?
Which of the following meetings, if any, do you plan to attend this year? (choose all that apply)
In a few sentences, what do you consider as key to making this a productive mentorship experience?
Would you be able to commit 2-4 hours a month to mentor in this program?
Clear selection
If you have been a mentor before in the program do you have any suggestions to make the experience better for you or the mentee?
How did you hear about the Mentorship Program?
A copy of your responses will be emailed to the address you provided.
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