BSSH Mentee Application Form

To apply for the BSSH Mentorship Scheme as a Mentee, please complete the application form below.

(Please note that BSSH are providing free professional training in mentoring for established consultant hand surgeons and setting up links between mentors and junior BSSH surgeons who have requested a mentor. There is no guarantee of a successful liaison)

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* 1. First Name and Surname

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* 2. E-mail

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* 3. Mobile telephone

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* 4. Orthopaedic or Plastic surgeon

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* 5. Current Job Title and Location

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* 6. BSSH membership (eg Full, Associate) & duration

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* 7. Date consultant post started, or is due to start (month/year)

Date / Year

Date

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* 8. Location of consultant post

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* 9. How many BSSH events have you attended in the last 5 yrs?

Scientific Meetings:

Instructional Course Lectures:

Other:

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* 10. Do you currently have, or have you previously had, any formal mentoring?

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* 11. You are applying for a BSSH mentor. When would you like that to commence?

Date / Time

Date

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* 12. How do you think a mentor might help you? (Maximum 50 words)

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* 13. Do you have any preferences as to your mentor’s location? (Please note if you are more likely to be able to meet face to face with a local mentor)

In my hospital group

Anywhere

In my region

Not in my Region

Other (please specify)

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* 14. Would you be happy to provide feedback?

Yes

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* 15. When more senior, might you consider acting as a mentor to other surgeons?

Yes

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* 16. For diversity monitoring, please let us know of the following:

Sex:

Ethnicity: