ANZSN Mentorship/Mentee Nomination Survey Question Title * 1. Would you like to participate in the mentorship program? Yes No Question Title * 2. Name Question Title * 3. I am interested in being a: Mentor Mentee Both Question Title * 4. If required, would you be willing to be a part of a group ( maximum 4 people) mentee/ mentor community Yes No Question Title * 5. Best way to start communication – email or phone number Question Title * 6. How do you describe your gender? Male Female Non-binary Prefer not to say Other (please specify) Question Title * 7. Would you prefer a mentor/mentee of a certain gender identity? No Yes (please specify) Question Title * 8. What term describes you best? Allied Health Clinician in Training Allied Health Clinician Medical Clinician in Training Medical Clinician (e.g. nephrologist, physician, surgeon) Nursing Clinician Nursing Clinician in Training Researcher (Scientist, Academic) Administration Clinician-researcher Other (please specify) Question Title * 9. Predominant work location- City and state Question Title * 10. If possible, would you prefer a local match? Yes No No preference Question Title * 11. Details of work Public Private Adults Peadiatric Special interests Teaching Research Question Title * 12. Where possible, is there any possible personal circumstances you would like us to consider in your matching process – examples include cultural identity, sexual identity or societal aspects ( single parent etc) Question Title * 13. Please rate which topics you would be interested in discussing with your mentor/mentee partnership ( 1 being most important) Question Title * 14. Please tick which areas of interest you would be interested in discussing with your mentor/mentee partnership First Nations Health Transplantation Peritoneal Dialysis Interventional Nephrology Vascular Access Haemodialysis Kidney Supportive Care Green Nephrology Glomerulonephritis Paediatric Nephrology Maternal Health Nutrition Bone Health Cardiovascular Health Discovery Science Other (please specify) Done