OD Virtual Mentoring- application form for mentees (January 2020)

Thanks for your interest!

We're delighted that you're interested in being mentored through the Do OD Virtual Mentoring scheme. Please complete the questions below by 27th January 2020. We'll be in touch soon! If you have any questions in the meantime, contact do.od@nhsemployers.org

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* 1. Name

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* 2. Organisation

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* 3. Job title

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* 4. What is your grade?

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* 5. Please select the region you work in.

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* 6. Email address

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* 7. Contact telephone number

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* 8. What are your top two OD related issues that you would like to raise with an OD mentor ?

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* 9. Have you been mentored before?

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* 10. Tell us a bit about yourself and your experience as an OD practitioner. This will help us to match you with the right mentor.

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* 11. What difference do you think having an OD mentor will make to your practice? What are your expectations?

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* 12. What help might you need to make the most of this opportunity?

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* 13. I confirm that I will commit to 3 virtual sessions with my mentor.

Yes

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* 14. I confirm I will take part in an evaluation after the sessions have taken place.

Yes

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* 15. What questions would you like us to answer?

The following questions are included so that we can monitor the programme for diversity and inclusion. You do not need to answer them if you do not wish to. The answers to these questions will be kept confidential (see our privacy policy below)

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* 16. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 17. What is your gender?

Female

Male

Other (specify)

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* 18. Which race/ethnicity best describes you? (Please choose only one.)

White/White British

Black/Black British

Asian/Asian British

Mixed race

Rather not say

Another race or ethnicity (please specify)

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* 19. Do you consider yourself to have a disability?

Yes

All information provided through this survey will be held by the NHS Confederation. Any personal data provided will be processed for OD Virtual Mentoring recruitment. The information collected will be processed via SurveyMonkey, on behalf of the NHS Confederation and will be shared with our partners NHS Leadership Academy and our trainers Black Gazelle Consulting for the purposes of recruiting mentors but will not be shared with any other third parties. Please see our privacy policy https://www.nhsconfed.org/about-us/governance-and-accountability/nhs-confederation-privacy-notice for further information on how we will handle your data and you may opt out from communications from us at any time.