PASS Mentor Program

Terms of Appointment

Name: / Date of Birth:
Address: / Registration Number:
Telephone:
Email:
With reference to the Mentor Program Guide, please indicate your suitability for the role in 500 words:

(1 represents little or no experience or competency and 5 represents expert)

Area / Degree of Competency / Comments
1 / 2 / 3 / 4 / 5
Professional Area:
Hospital Pharmacy
Community Pharmacy
Industrial Pharmacy
Pharmacist Contractor
Pharmacist Administrator
Pharmacist Academic
Other (Please specify)
Specialisms: (Please specify)
Skills:
Communication
Advocacy
Organisation and Time management
Giving Advice
Motivating people
Interpersonal Skills
Teaching/Training
Problem Solving
Project Management
Leadership
Research
Conflict Management
Period of Appointment
The terms of appointment of a PASS Mentor will be for one year, subject to review thereafter.
All appointments are subject to the continuing availability of appropriated funds of the PASS Charitable Trust. In the event that appropriated funding is not available, the PASS Mentor will be notified as soon as possible about the procedures for ending the appointment.
Financial Support
The pass Mentor is an unpaid, voluntary appointment. However travel expenses incurred as a result of participating in the program will be reimbursed in accordance with the procedure on expenses.
Obligations
During the appointment as PASS Mentor, each participant is subject to the rules and responsibilities of the Pharmacist Advice and Support Service, of which impartiality and confidentiality are of utmost importance.
Failure to adhere to the program requirements will, at the discretion of PASS, be a basis for revocation of the appointment.
The role of a PASS mentor is entirely voluntary. Those appointed are appointed as “volunteers” and have no employment rights or obligations.
Declaration
To the best of my knowledge and belief I declare that the information given in this form are a true and accurate description of my current circumstances. I consent to the Pharmacist Advice and Support Service storing any information given in this application in accordance with the Data Protection Act 1998.
Signed: / Date:

Please return completed application forms to the PASS Coordinator, Pharmacist Advice and Support Service at 73 University Street, Belfast, BT7 1HL, Telephone 90326927 or E-mail:

PASS is a registered charity in Northern Ireland NIC101811