Mentor application form

Mentor 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 mentor for the program please complete the form below. If you would like to take part in the program and receive mentoring, complete the form for mentees.

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: EXPERIENCE - SCOPE OF WORK

List any relevant undergraduate, postgraduate/professional development you have completed *

Please provide a brief overview of your experience in consumer advocacy including organisations you have worked for, nature and type of advocacy *

Please provide an overview of your areas of expertise in consumer advocacy (i.e. committee work, research, policy, education and training, governance, safe and quality use of medicines and medical tests)? *

SECTION 4: PERSONAL ATTRIBUTES OR INTERESTS

The following questions will help match mentors and mentees in relation to personal attributes and interests.

Please indicate 2 or 3 personality characteristics or personal attributes that make you an effective mentor *

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

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

At least 5 years' experience as a consumer advocate
Familiarity with the role of the NPS Medicine Wise and its scope of work
Genuine interest in supporting and guiding consumers in their advocacy journey
High level communication skills and ability to build effective relationships
Willingness to be open and reflect on own personal attitudes and style
Ability to provide sound, independent feedback and advice

Essential answer *

Desirable

Complete desirable criteria if applicable (approx. 100 words with 200 words maximum)

Previous experience as a mentor
Experience as a consumer advocate for NPS

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

Leave this field blank

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