Mentorship Programme 2024-2026 - Mentor Application Form

Dear Mentors,

Please complete this questionnaire to apply online to the ESAIC Mentorship Programme.
The questionnaire is currently open for Mentors. 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 Research Committee and ESAIC Mentorship Leader

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* 1. Contact Information

Title

Last Name

First Name

Email Address

Mobile Phone Number

Office Phone Number

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* 2. Personnal Information

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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* 3. ESAIC Information - Membership

What is your ESAIC Membership number ?

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* 4. 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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* 5. 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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* 6. Motivation (max 200 words) : Indicate here your motivation (e.g. Why would you like to become a mentor; etc)

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* 7. Describe briefly what personal strengths you can bring to being a Mentor (max 3 lines)

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* 8. What are your personnal interests/skills that you would like to share as Mentor?

	Yes	No
Research skills	Research skills Yes	Research skills No
Presentations and Lectures skills	Presentations and Lectures skills Yes	Presentations and Lectures skills No
Publications skills	Publications skills Yes	Publications skills No
Grant Programme applications skills	Grant Programme applications skills Yes	Grant Programme applications skills No
Applications for positions, fellowships, internships skills	Applications for positions, fellowships, internships skills Yes	Applications for positions, fellowships, internships skills No
Contracts bidding skills	Contracts bidding skills Yes	Contracts bidding skills No
Job interview skills	Job interview skills Yes	Job interview skills No

Other skills (please specify)

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* 9. What is your previous experience as Mentor (max 10 lines)

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* 10. Do you have any conflict of interest to declare ?

Yes

If yes, please specify

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

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* 13. 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 Mentee that I am matched with