If you have any questions about the application, please mail the Mentoring Programme team at mentoring@iiop.ie Complete the following form YOUR PROFILE Name: First Name Last Name Gender Male Male Female Female Gender diverse Gender diverse Phone Number Email Email Confirm email YOUR PHARMACY PRACTICE PSI Number Primary Practice area Primary Practice area - Select -CommunityHospitalIndustryEducationResearchOther (please specify) Enter other… Please list your qualifications Number of years qualified Areas of expertise/ special areas of interest Current Position Time in current role Describe yourself in 3 words Describe your ideal mentee in 3 words THE MENTORING PROGRAMME Why do you want to be a mentor? People come to mentoring for a wide range of reasons. To help us find a good match of a mentee for you, please let us know if there are any particular areas you would like to support your mentee in. EXPERIENCE- MENTORING Have you been a mentor or mentee previously informally or in a programme? - Select -Yes, Mentor onlyYes, Mentee onlyYes, both Mentor and MenteeNo, neither Mentor or Mentee If yes, please describe your experience (concisely) incl. duration of experience: Have you completed any training relevant to Mentoring, or developing others? Have you completed any training relevant to Mentoring, or developing others? - Select -No*Yes, I completed the IIOP Mentoring Skills Training Yes, I have completed additional relevant training e.g. Coaching skills, Coaching accreditation ( Please describe below) *please note at a minimum, applicants must have completed the Mentoring Skills Workshop to be eligible to act as a Mentor for this Mentoring Programme. TO ENSURE THE QUALITY OF THE PROGRAMME, WE ASK YOU TO DECLARE YOUR SUITABILITY TO PERFORM THE ROLE OF MENTOR IN THIS PROGRAMME. PLEASE REVIEW THE INFORMATION BELOW AND SIGN THE DECLARATION, AS APPROPRIATE. MENTOR SELF-ASSESSMENT EXPECTATIONS OF MENTORS (Click box to agree to all) Demonstrate a commitment to the development of others Explain the role of mentor and explore the expectations of my mentee Be objective and non-judgemental, I am not there to assess my mentees performance Provide perspective, knowledge, experience and guidance - Provide perspective, knowledge, experience and guidance Have protected time allocated for mentoring sessions and any preparation needed Evaluate the relationship periodically and follow through on commitments Refer to the IIOP Mentoring Programme Team if I need help or support I have completed the self-assessment above and considered the questions above I have completed the IIOP Mentorship Skills Training for pharmacists I commit to my ongoing development as a Mentor. I confirm I am in good professional standing. I confirm I will not use this position of influence for personal financial benefit I confirm that I am available on the evening of the 4th December for an onboarding session Name: Date Submit
