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Professional Information
Title of Current Position*
Type of Position*
Select Position
Staff Nurse
Visiting Nurse
Clinical Leader
Research
Management (please specify)
Educator
Other (please specify)
Current Employer Type*
Select Employer Type
Acute Care Hospital
Long Term Care
Residential Care
Community Care
Primary Care
Addictions and Mental health
Complex Continuing Care
Rehabilitation
Other
Number of Years in Current Position*
Mentor Information
Have you been a mentor?*
Yes
No
Why do you want to be a mentor for this program?*
What does your potential mentee need to know about you?*
Which of the following best describes your mentoring style?*
A motivator
An expert
A coach
An enabler
How do you prefer to communicate and interact with your mentee? Check all that apply.*
Face-to-face meetings and discussion
Telephone conversations
E-mail/Text communication
Web conferencing
Live chat ( i.e. SKYPE)
At which times would you prefer to interact with your mentee? Check all that apply.*
At an agreed upon with preset meeting times
Spontaneously as issues arise
Weekdays
Weeknights
Weekends
How much time are you willing to commit to a mentoring relationship?*
More than 1 hr a week
4 to 6 hours per month
2 to 3 hours every 3 months
2 to 3 hours every 6 months
How many mentees would you be willing to work with at one time?*
1
2
3
Other, please specify
Public Information
Public First Name*
Public last Name*
Private Information
First Name
Last Name
Email: *
Home Phone: *
Work Phone: *
Mobile Phone: *
Do you need to update your current information?
Edit Main Profile
By checking off this agree button you are saying yes to the OFAH
Privacy Policy
and you are also making a commitment to the mentorship relationship. This matching system provides the opportunity for mentor/mentee contact for which OFAH takes no responsibility - either for the suitability of relationship or the outcomes of the relationship.
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