PONL Mentorship - Mentor Application

PONL Nurse Leader Mentorship Program: Mentor Participation Form
Make this the year you give back by volunteering to mentor a fellow nurse leader. Your information will be part of a repository for mentees to choose from. You will be able to decline any request and will only be asked to follow through on those you accept. The time commitment per mentee is approximately 1 hour per month for 6 months.

Please see some of the tools and guidelines developed to help you understand the commitment and process:

Mentorship Program Guidelines

Mentorship Program FAQ

Mentor-Mentee Matching Process

Mentee Development Form

We appreciate you investing back into the future of nursing leadership and look forward to working with you.

As always, if you have any questions, please do not hesitate to contact Tricia at the PONL Office.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date available to start as a mentor*

MonthDayYear
Date
Number of Mentees you are able to support at the time of your start date
Current position/Title*
Organization/Employer*
Please upload your current CV/Resume*

Cancelof
Please upload your current headshot to be used on the Mentorship page of the PONL website*

Cancelof
Career Background and Experience.

Please check the categories that apply to you:
Level of Responsibility*

Senior ExecutiveVice PresidentCNODirectorManagerEducatorSupervisorAPRNOther
Level of Responsibility*

Senior ExecutiveVice PresidentCNODirectorManagerEducatorSupervisorAPRNOther
Type of Organization*

Hospital/Medical CenterHealthcare System LevelAmbulatory Care Facility/ClinicAcademiaBehavioral HealthLong Term Extended CareHome HealthHospiceGovernment/PolicyOther
Number of Years in Leadership/Management Roles:*
Please select the degrees you hold*

BSNMAMSNMBAMPHDNPPhDOther
Please select the certifications you hold*

CENPCNENEA-BCNE-BCOther
Scope of Excellence and Expertise
Please list your area(s) of expertise below:*
Nurse Leader Competencies: Communication and Relationship Building: Please select those areas of expertise below.*

Academic relationshipsCommunity involvementDiversity, Equity and InclusionEffective communicationInfluencing behaviorsMedical staff relationshipsNetworkingRelationship management
Nurse Leader Competencies: Knowledge of the Health Care Environment: Please select those areas of expertise below.*

Advocacy/health care policyCare managementClinical practice knowledgeDelivery models/work designEvidence-based practice/outcome measurementHealth care economicsInformaticsTechnology/AIPatient safety/Quality improvement/metrics/risk managementPopulation HealthRegulations and Compliance
Nurse Leader Competencies: Leadership and Professionalism: Please select those areas of expertise below.*

Systems and complex thinkingChange managementDecision makingTransformation and innovationProfessional accountabilityOrganizational accountabilityGovernanceEarly Career PlanningC-Suite Career Planning
Nurse Leader Competencies: Business Skills: Please select those areas of expertise below.*

Financial and business managementStrategic planning and managementHuman resources managementInformation technology and managementPerformance improvement and excellence
If you have any additional comments or information, please let us know here.
Commitment Statement

By signing below, I understand that participation as a mentor in the Nurse Leader Mentorship Program involves regular engagement, goal-setting, and collaborative support for my assigned mentee(s) during the designated program period. I agree to maintain professionalism, confidentiality, and accountability throughout the mentoring relationship.
Signature*
Should be Empty:

PONL Nurse Leader Mentorship Program: Mentor Participation Form

Career Background and Experience.

Scope of Excellence and Expertise