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ICA Mentorship Scheme - expression of interest (Mentees)

Personal details

Title*

First name*

Surname*

Telephone number*

Email address*

Current role*

Date of appointment to current role*

Professional background*

Further details

Training award name*

Training award start date (dd/mm/yy)*

Training award end date (dd/mm/yy)*

Please name your preferred mentor(s) (if known)

First choice

Second choice

Please indicate which of the following areas you would like your mentor to support you with.

Knowledge and intellectual abilities

Methodological advice
Critical thinking

Research governance and organisation

Applying for ethics
Applying for research grants

Engagement, influence and impact

Publication of research
Public speaking and dissemination of research
Networking skills
Enhancing national/international profile

Clinical academic leadership skills

Improving role performance

Personal effectiveness

Personal professional development
Decision making
Managing Transitions
Work-life balance
A sounding board for ideas
Encouragement and support
Overcoming obstacles

Other (please detail)

Are you willing to take part in evaluation of the mentorship programme?*

Yes
No

Are you willing to allow your biography and image to be used on the programme website and other publicity materials?*

Yes
No

Do you have any further comments?

Please note that the team will need to share some of your personal details with University of Birmingham for the purpose of registering you onto the Canvas online virtual learning environment, which will provide you with information on training and events as well as links to useful resources. If you would like to discuss this further or have any questions please email:

ICAMentorshipScheme@uhb.nhs.uk

Delivering the best in care

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