Mentee application form

Mentee application form

NPS MedicineWise and CHF are establishing a pilot Consumer Mentoring Program to help build the capacity and diversity of consumer representatives within the quality use of medicines sector. If you would like to be considered as a mentee for the program please complete the form below. If you would like to take part in the program as a mentor, complete the mentor form.

All expressions of interest will be assessed by panel consisting of a representative from CHF, NPS MedicineWise and two representatives from the NPS MedicineWise Consumer Advisory Group. If you have any questions please contact CHF Policy Officer Quality use of Medicines; Penelope Bergen at p.bergen@chf.org.au. Expressions of interest close at midnight on Thursday 31 Dec 2020. The information provided in your application form will be kept confidential and will only be shared with the selection panel.

SECTION 1: PERSONAL DETAILS & DEMOGRAPHICS

Title

First name *

Last name *

Address *

Mobile *

Email address *

In which state or territory do you live? Other - please specify

Would you describe where you live as: Other - please specify

Do you identify as Aboriginal or Torres Strait Islander? *

Aboriginal

Torres Strait Islander

Prefer not to answer

Gender *

Male

Female

Prefer not to answer

Other...

Gender Other...

Do you speak a language other than English at home? Other...

SECTION 2: REASONS FOR APPLYING (MAX 100 WORDS EACH)

Please provide 3 key reasons for applying to this program.

1. *

2. *

3. *

SECTION 3: PERSONAL ATTRIBUTES AND INTERESTS

The following questions will help match mentors and mentees in relation to needs and goals

Are there any specific areas you would like the mentoring to focus on or are there any specific challenges you are facing and would like to address? (eg governance, role and scope of NPS MedicineWise, research, technical terms)

Please indicate 2 or 3 personality characteristics or personal attributes that you think could make you a good advocate *

Please provide 2 or 3 areas of personal interest (i.e. travel, gaming, reading) *

SECTION 4: EXPERIENCE AND TRAINING AS A CONSUMER ADVOCATE

Please outline any experience you have had so far in consumer advocacy

Have you previously undertaken any training in consumer advocacy? *

Yes - please specify

Have you previously undertaken any training in consumer advocacy? Yes - please specify

SECTION 5: RESPONSE TO THE FOLLOWING SELECTION CRITERIA (MAXIMUM 600 WORDS)

Please ensure you respond to all essential selection criteria (approx. 100 words per criteria, maximum 600 words in total for this section).

Essential

Interested in developing advocacy skills and participating in a formal mentoring program
Meet one or more of the NPS priority areas: Which of the advisory groups are you willing to be considered for and why?
New to advocacy work or new to NPS or both
Willing to undertake advocacy work for NPS if successful
Willingness to be open, share information and receive constructive feedback

Essential answer *

Desirable

Complete desirable criteria if applicable (200 words maximum)

Have completed training as a consumer advocate? (Please specify what training, who provided it and when you completed it)

Desirable answer

SECTION 6: RELEVANT CHECKS

Must either have or be willing to obtain the following checks relevant to the mentoring program, if required:

Police and Criminal history
Working with Children

Is there any other information you would like to provide to support your application?

Maximum 250 words

SECTION 7: REFEREES

Please provide the names and contact details of two referees who would be willing to support your application.

REFEREE 1

Name: *

Position: *

Contact number *

Email: *

REFEREE 2

Name: *

Position: *

Contact number *

Email: *

THANK YOU FOR YOUR APPLICATION

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