Introduction

*First Name:

*Last Name:

*Email:

Current position title:

Would you like to participate in a mentoring program in _____ (Qtr or Year)?

Conditional follow-up response: If user selects ‘Not sure’ or ‘Neither’, they should get the following open text question:

Please let us know why you selected ‘Not Sure’ or ‘Neither’. Select all that apply:

Conditional follow-up response: If user selects ‘Other’, they should get the following open text question:

Please explain why you selected ‘Other’.

What type of mentoring program structure would best suit your interests:

Conditional follow-up response: Those who select Mentoring Circles should receive the following question:

What do you hope to gain from a mentoring circle (e.g.,specific expertise, best practices and support from colleagues, exposure to other areas and roles in the company, etc.).

As either a mentee or a mentor, how much time would you have/want to invest in a mentorship relationship?

What is your preferred mentoring program duration?

Conditional follow-up response: If user selects ‘Other’, they should get the following open text question:

Please let us know what you envision for program structure and duration.

Do you anticipate any blockers to your ability to commit the time required to participate? If so, please describe (e.g., management support, workload, travel, etc.).

Would you like the ability to select your mentorship partner:

When selecting a mentoring partner what criteria would be most important for you? Rank the following options, with 1 being the highest priority:

Conditional follow-up response: If user selects ‘Other’, they should get the following open text question:

Please let us know any other criteria that are important to you when being matched in a mentorship:

What areas would you like to mentor or be mentored on in a partnership? Check all that apply:

(Admin - Add your list here of what you are planning to offer as the focus for your program: Career pathing, leadership competencies, specific business skills, etc.)

What design elements should be included in a mentoring program? Select all that apply:

Conditional follow-up response: If user selects ‘Other’, they should get the following open text question:

Please explain why you selected ‘Other’.

Please use this space to include any recommendations about what would make a mentoring program meaningful to you:

Please use the space below to define or detail some other mentoring related activity/training that would enhance your career objectives: