Global Injury Prevention Network Mentorship Application Form

Contact Information (Information in this section will be displayed on the GIPN website) Organization: Contact Person’s Name: Title: Mailing Address: City: State/Province: Country: Postal Code: Telephone: Fax: Website: Email: Secondary Email: Preferred form of communication:  Email  Skype (User Name)  Phone  Other, please specify:

Other Information Language preference(s): ______

What mentorship role is currently most appropriate for your organization?  Providing mentorship to another organization  Receiving mentorship from another organization  There are some skills my organization could provide as a mentor and other skills my organization would like to receive from another mentoring organization

Key Skills: Mentor Organization Please rank (1, 2, 3, etc…) all skills that your organization would be interested in providing as a mentor. Advocacy / Policy Program monitoring and evaluation Communications/Media outreach Program sustainability/Funding support Design and planning of programs Surveillance Design, planning and conducting of research Other, please specify: Education and training Program implementation and management

Key Skills: Mentee Organization Please rank 1, 2, 3, etc…) all skills that your organization would be interested in receiving from a mentor organization. Advocacy / Policy Program monitoring and evaluation Communications/Media outreach Program sustainability/Funding support Design and planning of programs Surveillance Design, planning and conducting of research Other, please specify: Education and training Program implementation and management

There is no cost to join the Global Injury Prevention Network

Injury & Violence Topic Areas of Interest Please check all that apply.  Alcohol/drug-related injury  Injury biomechanics  Poisoning  Bicycle-related injury  Injury rehabilitation  Rape/Sexual assault  Bullying  Injury in the home  Sports-related injury  Child maltreatment  Intimate partner violence  Suffocation/Safe sleep  Choking  Motor vehicle-related injury  Suicide  Consumer product-related injury  Child passenger safety  Trauma systems/care  Drowning  Distracted driving  Traumatic brain injury  Elder abuse  Impaired driving  Youth violence  Falls  Motorcycle-related injury  Other, please specify:  Farm-related injury  Occupant protection  Fire/Burns  Pedestrian injury  Firearm-related injury  Teenage driving  Injury among children  Occupational injury  Injury among older adults  Playground-related injury

If interested in receiving mentorship from another organization, please provide a description of your organization’s current activities, the need or focus of the proposed mentorship, and what you would like to accomplish through the mentorship. How will this improve injury and violence prevention in your setting? (This information is important for identifying an appropriate mentorship match.)

There is no cost to join the Global Injury Prevention Network