CQI Community Mentorship Program Mentor Application

Mentor Application

Thank you for your interest in participating in our continuous quality improvement (CQI) professional mentorship program. During this 6-month program, mentor/mentee pairs will build a mutually beneficial relationship that will strengthen skillsets and support career growth. Please note that based on mentee applications and interests, not everyone who applies may be matched with a mentee.

There will be a required mentorship kick off meeting on March 20, 2025 and the program will run from April through September. Mentor/mentee pairs are expected to meet at least monthly over the course of the program. There will also be two mentor-only group check-ins (May 20th and August 26th) and an all-cohort session on July 10th during the program. The Closing session of the program will be on September 18.

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* 1. Background Information:

Your Name:

Preferred Pronouns:

Agency/Organization:

Agency/Organization Address:

Job Title:

Essential Job Functions:

E-mail:

Phone Number:

Number of years in the workforce:

Number of years working in quality improvement:

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* 2. Please upload a current resume:

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 3. Please share a current bio:

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* 4. Educational Background: Include the specific degree(s) below:

Bachelor’s degree(s):

Master's degree(s) and area(s) of concentrations:

Doctoral degree(s):

Other degrees or certifications:

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* 5. What is the structure of quality improvement at your organization? (e.g., separate department, embedded within the program, team, single person)

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* 6. Size of organization:

Very Small (Under $1M)

Small ($2-5M)

Medium ($5-10M)

Large ($10-25M)

Very Large (>$25M)

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* 7. Type of Organization:

Human Service Agency

Government Agency/Department

Healthcare

University/College

Other (please specify)

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* 8. Region served:

Local

Statewide

Multi-state

Other (please specify)

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* 9. Where do you fit within quality improvement at your organization? (e.g., part of the quality improvement department, program team, adjacent)

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* 10. Have you participated in a formal mentoring program before?

Yes