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ANZUP Mentorship Program – Mentee Application
1.
What is your current role/title
2.
What is your Organisation / institution
3.
What is your email addresss?
4.
How many years of experience do you have in your field?
Less than 1 year
1-3 years
4-5 years
6-10 years
10+ years
5.
Briefly describe your current role and responsibilities
6.
What do you hope to gain from participating in the ANZUP Mentorship Program? (Please include any short- and long-term goals)
7.
Which areas would you most like support in? (select up to 5)
Career pathways in clinical trials/research
Building confidence
Leadership development
Communication and presentation skills
Time management and prioritisation
Stakeholder engagement
Trial/project management
Managing challenging conversations
Problem solving and decision making
Working within multidisciplinary teams
Career progression
Work–life balance and wellbeing
Other (please specify)
8.
My primary focus for this program is
Building confidence
Career development
Developing leadership capability
General guidance and support
Other (please specify)
9.
Is there anything else that would help us match you with a mentor?
10.
How did you hear about the ANZUP Mentorship Program?
ANZUP email or newsletter
ANZUP ASM or event
Colleague or peer recommendation
Social media
ANZUP website
Other (please specify)
11.
I understand the expectations of being a mentee and will:
- Commit to meeting with my mentor approximately once per month
- Take responsibility for driving the mentoring relationship
- Be prepared, engaged and proactive
- Respect confidentiality and privacy
- Engage with any program resources provided
Yes
No
12.
I confirm I will communicate openly with my mentor and the program coordinator if my availability or commitment change
Yes
No
