Mentor and Mentee Data Collection Form - January 2023 - Gloucestershire Primary Care Workforce Centre

Please complete the below form to detail each of your Mentees, we are asking colleagues to reflect ;

Mentee Name
Hours mentoring completed to date
Location of mentee (Gloucestershire or Devon)

Please ensure you complete the above details for existing and previous mentees (who may have now concluded mentoring)

There is also a further question on the second page which asks for any additional capacity you may have.

Please note – In respect of hours, Mentors are funded 6 Hours Mentoring and a further 3 hours admin (total 9 hours per mentee)

Mentor Details – January 2023

Step 1 of 2

50%

Your Name(Required)

Email for Copy of Response

Your Primary Practice

Please complete the details of each mentee below. Detailing the hours offered so far and if they are a Gloucestershire or Devon Based GP.

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Please tick yes, if you have completed all 6 sessions with this Mentee (with an additional 3 hours of admin time) and therefore your Mentoring of this individual has now finished. If you have had additional hours approved by the Primary Care Training Hub and therefore your Mentoring relationship is continuing outside of the 9 hours please tick no.

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Mentee Name

Hours of Mentoring Completed

This should include any admin hours used to support the individual

Where is this Mentee Based

Gloucestershire

Devon

Have your Mentoring sessions with the individual come to an end ?

Yes

Not including your existing Mentees (detailed on the previous page). How many additional mentees do you have capacity to support?(Required)

Notes

Please use this box to document anything you feel may be helpful to the PCTH team (eg mentees wishing to pause mentoring) **Please do not record any sensitive or confidential information.**

Mentor and Mentee Data Collection Form – January 2023

Mentor Details – January 2023