Mentor Application Form-Mentorship Programme 2027-2029

Dear Mentors,

Please complete this questionnaire to apply online to the ESAIC Mentorship Programme.
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
On behalf of the ESAIC Research Committee and ESAIC Mentorship Leader

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1. Contact Information (Required.)

Title

Last Name

First Name

Email Address

Mobile Phone Number

Office Phone Number

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2. Personnal Information (Required.)

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

ESAIC Council member

ESAIC Board member

ESAIC Scientific Subcommittee member

No current/recent activity within ESAIC

Other (please specify)

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4. What are your Scientific Areas of Interests? (Required.)

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

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

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7. What are your interests/skills that you would like to share as Mentor? (Required.)

Research Skills

Presentations & lectures Skills

Publications Skills

Networking Skills

Grant Programme applications Skills

Applications for positions, fellowships, internships Skills

Bidding for contracts Skills

Job interview Skills

Other (please specify)

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8. What is your previous experience as Mentor (max 10 lines) (Required.)

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9. Do you have any conflict of interest to declare ? (Required.)

Yes

If yes, please specify

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10. How much time can you spend on the programme? (Required.)

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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11. I will make every effort to attend the Mentorship Programme Kick Off meeting at ESAIC Euroanaesthesia. (Required.)

I confirm

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12. I agree to the following : (Required.)

ESAIC’s Privacy Policy

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

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

Mentor Application Form-Mentorship Programme 2027-2029

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* 1. Contact Information (Required.)

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* 2. Personnal Information (Required.)

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

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* 4. What are your Scientific Areas of Interests? (Required.)

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

Question Title

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

Question Title

* 7. What are your interests/skills that you would like to share as Mentor? (Required.)

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

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* 9. Do you have any conflict of interest to declare ? (Required.)

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* 10. How much time can you spend on the programme? (Required.)

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* 11. I will make every effort to attend the Mentorship Programme Kick Off meeting at ESAIC Euroanaesthesia. (Required.)

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* 12. I agree to the following : (Required.)

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* 13. Please upload your CV in English (Required.)

1. Contact Information (Required.)

2. Personnal Information (Required.)

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

4. What are your Scientific Areas of Interests? (Required.)

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

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

7. What are your interests/skills that you would like to share as Mentor? (Required.)

8. What is your previous experience as Mentor (max 10 lines) (Required.)

9. Do you have any conflict of interest to declare ? (Required.)

10. How much time can you spend on the programme? (Required.)

11. I will make every effort to attend the Mentorship Programme Kick Off meeting at ESAIC Euroanaesthesia. (Required.)

12. I agree to the following : (Required.)

13. Please upload your CV in English (Required.)