MOLN Mentor/Mentee Application
Name
*
First Name
Last Name
Credentials / Certifications
*
Number of Years as an RN
*
MOLN District
*
Please Select
District A
District B
District C
District D
District E
District F
District G
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Highest Level of Education
*
Please Select
Associate
Bachelor
Master
Doctorate
Employer
*
Current Position
*
I am Interested in Becoming a:
*
Please Select
Mentor
Mentee
Do you Prefer to be Matched with a Mentor in Your Current Organization?
*
Please Select
Yes
No
No Preference
Email
*
example@example.com
Work Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact?
*
Please Select
Email
Work Phone
Mobile Phone
Number of Years in a Nursing Leadership Position?
*
Please Select
1-4
5-9
10-14
15-19
20+
30+
Setting
*
Please Select
Ambulatory Care
Clinic
Critical Access/Rural
Higher Education
Inpatient Care
Long Term Care / Senior Services
Metro Urban
Post-Acute Care
Public Health
School Nurse
Other Industry
Position Held (Check all that apply)
*
Charge Nurse
CNO/ VP
Consultant
Dean
Medical Sales
Nurse Educator/Faculty
Nurse Manager
Nursing Director
Quality Improvement Leader
Researcher
Retired
Staff Nurse
Supervisor
Other
Nursing Specialty
*
Please Select
Ambulatory Care Primary Care
Ambulatory Care Specialty Care
Med-Surg
ICU
Ortho
Neuro
Surgical Services (OR/PACU)
GI/GU
Women’s Health
Pediatrics
Oncology
Cardiovascular
ED
Public Health
School Nurse
Home Health
Hospice/Palliative
Other
Academia
Professional Development/Education
Nursing Practice
Safety & Quality
Infection Prevention
Informatics
If Other, Please Fill in Blank
Do you Have Experience Serving as a Mentor?
*
Yes
No
I would be most comfortable mentoring those who are: (check all that apply)
*
Early in my career and aspiring to a leadership role and / or professional development
New to leadership and a strong desire to learn
Looking for the next step in my career
Experienced leader with specific mentoring needs
Other
What Strengths do you Possess or Experiences you Have had That Would be Helpful in a Mentoring Relationship?
*
Maintaining balance between professional and personal life
Building identity and purpose
Emotional intelligence
Lifelong learning
Building a nurturing community
Managing the transition from nurse to nurse leader
Learning from challenges and adversity
Managing organizational change
Managing competing priorities
Planning and organization
Communication, verbal and written
Setting the vision
Quality and performance improvement
Healthcare business knowledge: i.e. finance, marketing
Developing people and teams
Performance management
Other
What Mentor Attributes or Experiences Would be Helpful in a Mentor?
*
Maintaining balance between professional and personal life
Building identity and purpose
Emotional intelligence
Lifelong learning
Building a nurturing community
Managing the transition from nurse to nurse leader
Learning from challenges and adversity
Managing organizational change
Managing competing priorities
Planning and organization
Communication, verbal and written
Setting the vision
Quality and performance improvement
Healthcare business knowledge: i.e. finance, marketing
Developing people and teams
Performance management
Other
Which best describes you and your leadership experience?
*
Please Select
Early in my career and aspiring to a leadership roller professional development
New to leadership and a strong desire to learn
Looking for the next step in my career
Experienced leader with specific mentoring needs
Other
If Other, Please Fill in Blank
What are your career goals?
*
Where do you see yourself in 3-5 years?
*
Why are you interested in serving as a mentor?
*
Any additional information you would like to share about yourself?
Are you Willing and Able to Commit 1-2 Hours per Month to the Mentorship Program?
*
Yes
No
Please upload your CV/Résumé
*
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