Pairing Survey for the Mentorship Program

Preliminary Information

Name

First Last

What do you like to be called?

How did you hear about us?

Email Address*

Phone Number

Employer/School Attending

Title

Nature of Career Activity / Focus of Study or Anticipated Degree

Years of Experience / Year of Anticipated Graduation

Social media and other contact information

(Personal website, LinkedIn, Twitter, Facebook, other)

Age Range:

What role(s) are you interested in performing in the Mentorship Program? (Note your answer to this question will populate this form with questions corresponding to your selection.)

How much time are you willing to devote to a mentoring relationship?

How many previous mentors (formal and informal) have you had in your career?

Did you participate in a previous Mentorship Program with us?

How many people have you previously mentored (formally or informally) in your career?

How structured would you like your Mentor/Mentee relationship to be? (By "talk," you should assume that this might be in person, by phone, or electronic means) (Check all that apply)

Very structured (talk at set times on a regular basis)
Moderately structured (talk at designated times in a month, but with more scheduling flexibility)
Somewhat structured (mentor is available to talk a designated number of times in a month)
Minimally structured (talk when mentee wants advice, but there are no set times except for the scheduled group meetings)

What is your preferred method of communication with your Mentor/Mentee?

Other:

Please rank your preference for each of the following venues for mentor/mentee meetings:

Other:

Describe "other" preferred venue, if applicable:

How do you spend your time outside of work? Please share your hobbies, interests, volunteer work, charitable activities, community, or other pursuits.

How long have you been living in your city?

Is there any other information about you or ideas you would like to share with us that you believe might be relevant to a mentorship?

Prospective Mentees

On a scale of most important to least important, rank what you most want out of a mentoring relationship at this time

	Most important	Important	Neutral	Less important	Least important
Coaching on issues relating to my field of work
Positioning myself for career advancement or career transition
Expanding my professional network
Advice on leadership skills and how to get promoted (not necessarily within my current organization)
Help with specific challenges in my current position (such as resolving conflicts, accessing career-relevant resources, working in a male-dominated environment/industry, building relationships inside and outside my company)
Harassment and #MeToo
Obtaining introductions to specific people in my industry or profession
Encouragement and guidance related to life and career (help with work-life balance and setting boundaries)
New opportunities

Describe any other aspects you want out of a mentoring relationship (if applicable)

Would you be agreeable to working with a male mentor?

Would you be comfortable dealing across social identities in addition to gender?

What word best describes your ideal mentor at this stage in your career?

Describe Other, if selected

Where would you like to see your career in 5 years?

Describe Other, if selected:

What is your ultimate business/professional aspiration?

Describe Other, if selected:

What learning style do you feel will help you work most comfortably and confidently during your mentorship?

Are you interested in being a mentor to a student while being a mentee?

What are you hoping to accomplish by participating in the Mentorship Program?

Please list up to four topics for discussion that would be of particular interest to you in advancing your goals.

Is there any additional information you seek in the following categories? A.) Your industry in general

B.) The functional aspects of your industry (HR, IT)

C.) Your personal goals

D.) Diversity and Inclusion

E.) Other areas you wish to develop that are not listed

Prospective Mentors

You indicated above that you have previous experience as a mentor. How successful was that mentorship experience in your opinion?

Are you interested in mentoring a student, a woman in the early stages of her career, or either?

As a Mentor, rate your willingness to help your Mentee in the following ways

	Very willing	Willing	Neutral	Less than willing	Not at all
Teach career advancement skills
Teach leadership skills
Discuss #MeToo
Provide advice about what to do in specific situations, such as resolving conflicts and working in a male-dominated culture
Teach skills relevant to my mentee's line of work
Introduce my mentee to specific people in an industry to help her build her professional network
Share my contacts
Diversity and Inclusion
Advancing across different social identities, such as Race/Ethnicity, Age, LGBTQIA+, Motherhood/No Children
Working from home and surviving in a digital world
Other

Describe Other, if selected:

List any other ways you are willing to help your Mentee (if applicable):

What are you hoping to accomplish by participating in the Mentorship Program?

Are there any other considerations you would like us to be aware of in assigning you a Mentee?

	Most desirable	Least desirable
Mentor or Mentee's Office
Virtual (Especially for Those Outside Chicago)
Other (describe below)

Mentorship Program Pairing Survey

Preliminary Information

Prospective Mentees

Prospective Mentors

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