Thank you for completing this survey. Information collected will be kept confidential and secure by the WASHA Executive Committee. If you have any questions, please email: b.mills@ecu.edu.au

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* 1. Name

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* 2. Qualification(s)

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* 3. Organisation

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* 4. Role or position

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* 5. Postcode

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* 6. Mobile phone number

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* 7. Email address

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* 8. Are you interested in participating in a WASHA-administered mentorship program as a Mentor or Mentee?
Note that this is a WA-based program and even if you have minimal research expertise, please consider acting as a Mentor. Anyone with a PhD or experience as a peer-reviewed author should consider being a Mentor.

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* 9. If WASHA was to set up and administer this mentorship program, how likely do you think you would take up this opportunity? Please move the slider below to record your answer.

1 = this is a fleeting fancy and when the crunch comes, I probably wouldn't do it due to other commitments or lack of interest 100 = I would definitely commit to this program
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i We adjusted the number you entered based on the slider’s scale.

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* 10. Do you have any other comments about a WASHA-administered mentorship program you would like to make to the WASHA Executive Committee?

Thank you for your interest in a mentorship program.
Responsibility for this form is taken by Richard Riley [richard.riley@nd.edu.au]

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