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South Central Association of Blood Banks
South Central Association of Blood Banks

2901 Richmond Road, Suite 130-176
Lexington, KY 40509
Phone: (866) 649-6550 Fax: (866) 649-6590

Protégé Mentorship Program

Mentor Application

 
 

Name:
Street Address:
City:
State:
Zip:
Daytime Phone:
Alternate Phone:
Email Address:
   

Background Information*:

   
Education:
Certification:
MT SBB Other
Industry Experience
Number of Years:
Employer:
Title:
   
SCABB Member:
Number of Years: (2 Years Required)
Mentor Experience:
Number of Years:
 
* May email curriculum vitae to scabb@scabb.org to provide the info in this block.
   

Past Industry Experience:

   
Donor Collections
Donor Testing
Transfusion Service
Personnel Supervision
Quality Control / Assurance
Policy / Procedure Development
Training / Education
Recruitment
Marketing / Public Relations
SCABB Active Participation (Required)
 
Describe Active SCABB Participation:
   

Which Skills Would You Like to Develop / Strengthen?

   
Article Publication
Abstract Publication
Workshop Presentation
Inservice Preparation
Networking / Benchmarking
Association Involvement
Association Leadership
Career Development
Challenge Resolution
Solution Development
CV Enhancement
 
   

Mentor Participation Agreement

   

CONFLICT OF INTEREST: Any member of the South Central Association of Blood Banks (SCABB) shall make known any potential or actual conflict of interest, to any official SCABB group in which he/she participates.

INTERPRETATION: A conflict of interest should be considered as any potential or actual financial or proprietary interest in subject matters under discussion by, or within the charge of the group. Such an interest shall arise when a member is in the employ of, or provided consultative or other similar services to, a manufacturer of products which might be utilized by the institutional or individual members of SCABB and whose interest may be affected by the group’s activity. Further, it is possible that a conflict of interest could arise when a member has reason to protect the academic, medical or scientific reputation of himself, his associates, or his institution.

However, it is recognized that members with a conflict may be one of the leading experts on the subject matter or may have skills or talents useful to the activity in which a potential conflict exists and the SCABB should have the benefit of their expertise. Members with a conflict of interest should be permitted to participate in any activity, but only after their conflict on the matter has been made known. It is not necessary that all details of the conflict be divulged to the rest of the group.

SCABB will include a statement about conflict of interest in the invitation sent to members inviting them to accept appointment to SCABB groups. Members should accept these appointments only after they have been made aware that they will be expected to divulge actual or potential conflicts of interest.

CONFIDENTIALITY: As part of the mentoring process, a significant amount of personal information and/or proprietary information may be disclosed between the protégé and the mentor. All such information is to be considered extremely confidential and cannot be shared in any manner outside the protégé/mentor relationship without the prior, written consent of the individual and/or organization.

PARTICIPATION: I agree to participate in the Protégé Mentorship Program as described in the program description. My signature indicates my understanding and acceptance of the policies explained above and all my questions have been answered.

   
Mentor Name:
Date: