Mentorship Programme 2024-2026 - Mentee Application Form

Dear Mentees,

We have developed a questionnaire for you to apply online to the ESAIC Mentorship Programme.
The questionnaire is currently open for Mentees.
This questionnaire should only be completed once.

If you have any questions please contact mentorship@esaic.org

We thank you in advance.
Sincerely,

The ESAIC Research team
for the ESAIC Mentorship Programme Leader

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* 1. Please indicate what type of Mentee you are applying to be:

Emerging professionals (Early career anaesthesiologists/Intensivists with less than 6 years of experience in the field or residents currently training in Anaesthesiology/Intensive care.)

Tenure track (Anaesthesiologists/Intensivists at the level of the associate professor who plans to develop a career in academic anaesthesia/intensive care.)

Other : please describe

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* 2. Contact Information

Last Name

First Name

Email Address

Mobile Phone Number

Office Phone Number

Nationality

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* 3. Personnal Information

Year of Birth

Year of obtaining Degree of Medical Doctor

Year of obtaining Degree of Specialty in Anaesthesia/Intensive care

Hospital/Institution Name

Country of your Institution
(should be an European country as defined by the World Health Organisation https://www.euro.who.int/en/countries)

City of your Institution

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* 4. ESAIC Information - Membership (To be eligible, you must either be an ESAIC Active, Trainee or Allied member)

What is your ESAIC Membership number ?

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* 5. ESAIC Information - Current activity in ESAIC (or in the past 5 years) as :

ESAIC Council member

ESAIC Board member

ESAIC Scientific Subcommittee member

No current/recent activity within ESAIC

Other (please specify)

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* 6. What are your Scientific Areas of Interests?

1. General Anaesthesiology

2. Ambulatory Anaesthesia

3. Regional Anaesthesia

4. Obstetric Anaesthesiology

5. Paediatric Anaesthesiology

6. Neuroanaesthesiology

7. Cardiothoracic and Vascular Anaesthesiology

8. Acute and Chronic Pain Management

9. Intensive Care Medicine

10. Resuscitation, Emergency medicine and Trauma

11. Respiration and Airway Management

12. Transfusion, Haemostasis and Thrombosis

13. Pharmacology

14. Monitoring, Ultrasound and Equipment

15. Geriatric Anaesthesiology

16. Ethics

17.Patient Safety

Other (please specify)

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* 7. Motivation (max 200 words) : Indicate here your motivation (e.g. Why would you like to become a mentee; etc)

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* 8. Describe briefly what personal strengths you can bring to the Mentorship Programme (max 3 lines)

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* 9. Describe 3 developmental needs you would like to improve, in order of priority (max 5 lines per developmental need)

Priority #1

Priority #2

Priority #3

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* 10. Are you currently taking part in another Mentorship Programme (in your country; your university; another Society…)?

Yes

If Yes, please specify

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* 11. How many years of experience have you in the field of anaesthesiology or intensive care?

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* 12. How much time can you spend on the programme?

1 to 2 hours per week

1 to 2 hours per 2 weeks

1 to 2 hours per month

1 to 2 hours every 2 months

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* 13. I confirm that my English is a high enough standard to participate in the Mentorship Programme (please assume that all communication with your Mentor and the ESAIC Research Team will be in English)

I confirm

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* 14. I declare that I will send to mentorship@esaic.org the following documents:

Letter of recommendation from my Head of Department

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* 15. I agree to the following :

ESAIC’s Privacy Policy

ESAIC’s Terms and Conditions

My data being shared with the Mentorship Programme Leader and Review Panel

My CV being sent to the Mentor that I am matched with

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* 16. I agree to my contact details (email and phone number) being shared with the Mentee Club if I am selected as a Mentee

I agree