Application Survey - Vernissage Health Leaders Dialogue Series (Alumni Continuing Education Program)

Thank you for taking the time to complete this registration survey. This survey will take approximately 15-20 minutes of your time. The primary objective of the survey to assist the Project Faculty  understand your current leadership focus, learning needs and leadership goals.  This will indicate whether this program is the right offering for you at this stage of your career.  

Based on information submitted in this application, applicants will be short listed for an interview with Project Faculty to determine eligibility for participation.  In addition, if you receive an offer of participation in the program, your survey answers will assist the Project Faculty assign or “match” you with an established leader/mentor for 1:1 leadership coaching.  

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* 1. Contact Information:

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* 2. Please indicate the year of graduation from IHPME/DLSPH:

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* 3. Please indicate your graduate program at IHPME/DLSPH:

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* 4. For the purposes of Vernissage Health, health leadership roles are broadly defined. Please indicate your current leadership role/title? ¬¬¬¬¬¬Select the role that most closely aligns with your present position.

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* 5. Please indicate the type of organization in which you are currently employed:

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* 6. Please indicate your career stage in health leadership:

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* 7. Tell us about yourself as a leader. Please include some of your current beliefs, goals, frustrations, or aspirations for health leadership. Please briefly describe your current leadership role and what leadership challenges you face in your current role.

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* 8. Please briefly describe your career goals in health leadership.  What are you most passionate about leading?  How would the experience of this dialogue series and being the recipient of personal leadership coaching contribute to or support your goals?

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* 9. Please briefly describe your learning objectives in health leadership.  Where do you think you need to improve as a leader? What values, skills or competencies do you want to address and develop while participating in the program?

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* 10. Tell us the environment which allows you to best learn and grow? What type of mentorship or coaching do you feel would be most beneficial to your development as a leader? During this series, are you willing to go outside your comfort zone, take risks and be authentic as a leader?

Thank you for completing this application survey.

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