ACvA Mentee Questionnaire Question Title * 1. Name Name Institution Job title Email Address Question Title * 2. Career level Group leader or laboratory head Clinical fellow Allied health professional Postdoctoral researcher Research assistant/technician Honours or Higher Degree Researcher student Other (please specify) Question Title * 3. Gender Male Female Prefer not to say Question Title * 4. Date PhD/Masters was awarded or expected completion date (year)? Question Title * 5. Are you a (check all that apply): Discovery scientist (basic, preclinical) Translational scientist Public health professional Allied health professional Clinician Clinician scientist Other (please specify) Question Title * 6. What are you main areas of expertise? Question Title * 7. Does your main area of expertise involve patient engagement? Yes No Question Title * 8. Where do you ultimately want to end up in your career (role, position)? Question Title * 9. What sector would you prefer your mentor to be from? (please note that the focus of this program is to pair mentees with a mentor outside their area of expertise) Industry Governance/Policy Clinical Academia Other (please specify) Question Title * 10. What are your desired goals of being paired with a mentor? Question Title * 11. How frequently would you like to meet with your mentor? Question Title * 12. Are there any particular skills that you would like your mentor to have? Question Title * 13. Is there a specific mentor you would like to be paired with (if possible)? Question Title * 14. If you have any other comments for us, please write them here Question Title * 15. Please attach a 2 page CV PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please attach a 2 page CV Done
