Fellowship Application

Step 1 of 4

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Name(Required)

First Name Last Name

E-mail(Required)

Job Title(Required)

Organisation(Required)

Country(Required)

Linkedin Profile URL(Required)

I am Joining as :(Required)

An in-house safety leader or executive

A consultant, independent advisor or academic

1. QUALIFICATIONS & CREDENTIALS(Required)

BSc

MSc

Professional certification

Chartered Status

Others

Feel free to provide details - optional

2. YEARS OF EXPERIENCE IN LEADING HEALTH & SAFETY AT AN EXECUTIVE LEVEL(Required)

0 to 5 years

5 to 10 years

10 to 20 years

More than 20 years

Feel free to provide details - optional

3. DEPTH OF EXPERTISE(Required)

Describe briefly your safety culture experience.

4. YOUR PROFESSIONAL INFLUENCE INCLUDES CONTRIBUTION IN :

Committees

Advisory boards

Professional trade associations

Editorial boards

Academic publications

Describe briefly your safety culture influence - optional

5. YOUR PROFESSIONAL DEVELOPMENT INCLUDES

Participation in conferences

Formal training

Professional trade associations

Other development activities

Describe briefly your recent development actions - optional

6. ATTACH A CV (optional)

Accepted file types: jpg, pdf, png, Max. file size: 20 MB.

Tell us how you've shaped safety as a strategic priority. Answer the 5 questions below: 100 words max per question

1. ORGANISATIONAL INFLUENCE | SAFETY AS STRATEGIC PRIORITY(Required)

2. DEMONSTRABLES OUTCOMES(Required)

3. LEADERSHIP OF CHANGE | RESOURCE AND ACCOUNTABILITY DECISIONS(Required)

4. CROSS SECTOR CONTRIBUTION(Required)

5. THOUGHT LEADERSHIP | CRISIS LEADERSHIP(Required)

Share how you've contributed to the profession and your community beyond what your role required. Answer the 5 questions below: 40 words max per question.

1. MENTORING AND COACHING | FUTURE LEADERS(Required)

2. STEWARDSHIP OF THE PROFESSION AND GOVERNANCE(Required)

3. VOLUNTEERING AND PRO BONO ACTIVITY | VOLUNTARY CONTRIBUTION(Required)

4. COMMUNITY & INCLUSION(Required)

5. ADVOCACY AND PUBLIC LEADERSHIP(Required)

Fellowship application

Tell us about yourself