Mentee Application Worksheet
NCHPP CEO/Executive Director Mentoring Program
Mentee Application Worksheet
NCHPP CEO/Executive Director Mentoring Program
Applications for the CEO/Executive Director Mentor Program are accepted online. It is recommended that you use this worksheet to prepare your answers; then paste the responses into the online form. You must complete the online for in one session.
You will need to upload your resume through the online application system. Make sure you have access it when you are ready to submit your application. Your resume will be provided to your mentor and his/hers will be provided to you.
Online Mentee Application:
Mentee Questions
- What motivates you to seek a mentor?
- Describe key leadership skills you feel you have and any you would like to develop?
- Are there any specific qualities you are looking for in a Mentor?
- What aspects of your job do you enjoy the most?
- What aspects of your job challenge you the most?
- Identify any specific programs or services that you would like to develop within your organization.
- Identify 3 specific measurable goals (in priority order) you would like to work toward/achieve in your work with a mentor.
Goal 1.
Goal 2.
Goal 3.
Program Demographics
Mentee Application Worksheet
NCHPP CEO/Executive Director Mentoring Program
Service Area
Urban
Suburban
Rural
Mixed-Urban/Suburban/Rural
Agency Type
Free Standing
Home Health Based
Hospital Based
Nursing Home Based
Ownership Type
Continuing Care Retirement Community
Division of a Prison
Health Plan/Managed Care/HMO
Hospice Corporate Chain
Independent/Freestanding
Integrated Health System
Other (please explain):
Tax Status
Non-profit
For Profit
Government
Accreditations(select all that apply)
Accreditation Commission for Health Care (ACHC)
Community Health Accreditation Program (CHAP)
Joint Commission (formerly JCAHO)
Other (do not include Medicare/Medicaid)
Average Daily Census:
Patients Served Annually:
EMRSystem:
Additional Services My Organization Provides (select all that apply)
Community Bereavement Program
Complementary Therapies Program
Day Care Services for Hospice Patients
Hospital Based Teams
Inpatient Facility
Nursing Home Teams
PACE/Other Continuum of Care Program
Palliative Care Services
Pediatric Palliative Care
Post-Hospice Support for Patients Discharged Alive
Thrift/Resale Store
Other Services Provided
Mentee Application Worksheet
NCHPP CEO/Executive Director Mentoring Program