Mentoring Program Application Form

ROLE

Please select your preferred role

Mentor (an experienced and trusted adviser; training a less experienced colleague); orMentee (a person who is advised, trained, or counselled by a mentor).

TERMS & CONDITIONS

*I agree to the terms and conditions of the PSA Mentoring Program.

*I have read and understand the PSA Privacy Policy for collection and use of my personal data

*I give permission for PSA to disclose personal information entered into this form to prospective candidates

*Cost for the mentoring program is $100 for Mentees. By proceeding with registration I confirm I will be invoiced for the total program amount

*As a mentor I will supply a brief biography and digital photograph and agree that these will be displayed on the PSA web site

Options marked with a * are mandatory fields

CONFIRM YOUR DETAILS

Title

First name:

Last name:

Preferred name:

Date of birth

Gender

Home address

Suburb

State

Post code

Email

Home Phone

Work phone

Mobile phone

Employer (or University if studying)

EXPERIENCE

Qualifications

Primary mode of employment

Primary employment area

Estimated working hours per week

Secondary employment area

AREAS OF PRACTICE

Please tell us your number of years experience in each of the following areas

Academia/Research

Community pharmacy

Consultant

Government

Hosiptal pharmacy

Intern

AREAS OF PRACTICE

Please tell us your number of years experience in each of the following areas

Non-government organisation

Pharmaceutical industry

Student

Other (Non-Pharmacy)

Other (Pharmacy)

MENTEE ROLES

Please identify the role that you would like to be mentored in by order of priority.”

Aboriginal Health Pharmacist

Academic

Accredited Medication Review Pharmacist

Advanced Practice Pharmacist

Asthma Educator

Community Pharmacist

Compounding Pharmacist

Credentialed Diabetes Educator

Drug or Medicine Information Pharmacist

General Practice Pharmacist

Goverment Pharmacist

Hospital Pharmacist

Industrial Pharmacist

Military Pharmacist

Pharmacy Manager - Community

Pharmacy Manager - Hospital

Pharmacy Owner

Professional Services Pharmacist

Publications

Regulatory or Medical Affairs Officer or Manager

Researcher

Residential Care Pharmacist

Sales and Marketing Representative or Manager

Other (please specify)

Other

MENTEE TOPICS

Please identify the topics that you would like to be mentored in by order of priority.

Aboriginal and Torres Strait Islander health

Aged care

Cancer/palliative care

Cardiovascular

Complementary medicine

Dermatology

Diabetes

Digital health

Government and health policy

Immunisation

Infectious diseases

Mental health

Opiod replacement therapy

Paediatric

Pain management

Pharmacogenomics

Professional services implementation

Respiratory

Rural and remote pharmacy

Weight management

Wound management

Other (please specify)

Other

MENTOR ROLES

What roles have you had experience in within the last 15 years? Please tell us your number of years' experience

Aboriginal Health Pharmacist

Academic

Accredited Medication Review Pharmacist

Advanced Practice Pharmacist

Asthma Educator

Community Pharmacist

Compounding Pharmacist

Credentialed Diabetes Educator

Drug or Medicine Information Pharmacist

General Practice Pharmacist

Goverment Pharmacist

Hospital Pharmacist

Industrial Pharmacist

Military Pharmacist

Pharmacy Manager - Community

Pharmacy Manager - Hospital

Pharmacy Owner

Professional Services Pharmacist

Publications

Regulatory or Medical Affairs Officer or Manager

Researcher

Residential Care Pharmacist

Sales and Marketing Representative or Manager

Other (please specify)

Other

MENTOR TOPICS

Are you a subject matter expert in any of the following areas? Please tell us your number of years' experience.

Aboriginal and Torres Strait Islander health

Aged care

Cancer/palliative care

Cardiovascular

Complementary medicine

Dermatology

Diabetes

Digital health

Government and health policy

Immunisation

Infectious diseases

Mental health

Opiod replacement therapy

Paediatric

Pain management

Pharmacogenomics

Professional services implementation

Respiratory

Rural and remote pharmacy

Weight management

Wound management

Other (please specify)

Other