OOTA Mentorship Pre-Program Survey

Company

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Participant Role(Required)

Years of Experience in OT:(Required)

Primary Practice Setting(s):

Student

Hospital

School

SNF

Outpatient

Home Health

Academia

OOTA District:(Required)

Northwest (Allen, Crawford, Defiance, Fulton, Hancock, Hardin, Henry, Lucas, Ottawa, Paulding, Putnam, Sandusky, Seneca, Van Wert, Williams, Wood, and Wyandot Counties)

West Central (Dayton Area – Auglaize, Champaign, Clark, Darke, Greene, Logan, Mercer, Miami, Montgomery, Preble, and Shelby Counties)

Central (Columbus Area – Delaware, Fairfield, Fayette, Franklin, Knox, Licking, Madison, Marion, Morrow, Pickaway, Union, Coshocton, Perry, and Muskingum Counties)

Southwest (Cincinnati Area – Butler, Clermont, Clinton, Hamilton, and Warren Counties)

North Coast (Cleveland Area – Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, Medina, and Ashtabula Counties)

North Central (Akron Area – Ashland, Carroll, Harrison, Holmes, Portage, Richland, Stark, Summit, Tuscarawas, Wayne, Columbiana, Jefferson, Mahoning, Trumbull, Belmont, Guernsey, and Monroe Counties)

South (Brown, Highland, Adams, Pike, Ross, Scioto, Jackson, Vinton, Hocking, Lawrence, Gallia, Meigs, Athens, Noble, Morgan, and Washington Counties)

What specific areas of your professional or personal development do you hope to address through this mentorship?(Required)

What do you hope to gain from participating in this program?

Networking (e.g., connecting with peers or leaders in your field)

Specific skill development (e.g., public speaking, technical skills, time management, conflict resolution)

Career guidance (e.g., goal setting, promotion strategy, career pivots, job search support)

Confidence (e.g., imposter syndrome, decision-making, leadership presence)

Accountability (e.g., staying on track with personal or professional goals)

Industry knowledge (e.g., trends, best practices, insider perspectives)

Work-life balance or well-being strategies

Feedback on specific projects or challenges

Other (please specify)

If you said "other" above, please specify(Required)

On a scale of 1-5 (1=Not confident, 5=Very confident), how confident are you that this program will help you achieve your goals?(Required)

What do you hope to contribute to your mentee's professional or personal development?(Required)

What do you hope to gain personally or professionally from participating as a mentor?

If you selected "other" above, please specify(Required)

On a scale of 1-5 (1=Not confident, 5=Very confident), how confident are you in your ability to effectively mentor someone through this program?(Required)

Current Perceived Skill Levels (Self-Assessment):

Rate your current level of proficiency in the following areas on a scale of 1-5 (1=Novice, 5=Expert).(Required)

	1	2	3	4	5
Clinical Skills: (e.g., specific assessment techniques, intervention strategies for various populations, documentation)
Professionalism & Ethics: (e.g., ethical decision-making, professional conduct, advocacy)
Communication Skills: (e.g., active listening, effective feedback, conflict resolution)
Leadership & Management: (e.g., delegation, team collaboration, project management)
Research & Evidence-Based Practice: (e.g., literature review, applying research to practice)
Career Development: (e.g., goal setting, career planning, networking)
Work-Life Balance & Well-being: (e.g., stress management, self-care)

What kind of mentorship approach do you prefer?

If you said "other" above, please specify(Required)

Are there any specific topics or areas you are particularly eager to focus on with your mentor? Examples to help you brainstorm (do not select, just for inspiration):

Navigating office politics or organizational culture
Preparing for a promotion or leadership role
Improving public speaking or presentation skills
Building a personal brand or online presence
Managing up or working with difficult stakeholders
Transitioning into a new industry or role
Work-life balance or avoiding burnout
Technical skills (e.g., coding, data analysis, design tools)
Conflict resolution or difficult conversations
Strategic thinking and decision-making

Specific topics:

OOTA Mentorship Pre-Program Survey

Current Perceived Skill Levels (Self-Assessment):

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