Scholar Nomination Questionnaire


	Welcome to the NMQSLA 2024 Scholar Nomination Questionnaire! Thank you all for your interest in the Navy Medicine Quality and Safety Leadership Academy (NMQSLA)! The questionnaire below is comprised of four sections requesting various pieces of information pertinent to your attendance and potential acceptance to the program. If at any time you have questions about the questions below, please do not hesitate to reach out to the NMQSLA Support Team at usn.ncr.bumedfchva.mbx.qualityand-safetyleadershipacademy@health.mil. Please follow this link to complete the questionnaire on DoD SharePoint: https://esportal.med.navy.mil/bumed/rh/m5/NavyMedicineHighReliabilityNetwork/Lists/NMQSLA%202024%20Scholar%20SelfNomination%20Form/NewForm.aspx?Source=https%3A%2F%2Fesportal%2Emed%2Enavy%2Emil%2Fbumed%2Frh%2Fm5%2FNavyMedicineHighReliabilityNetwork%2FLists%2FNMQSLA%25202024%2520Scholar%2520SelfNomination%2520Form%2Foverview%2Easpx 1. Please fill in the following information. First Name Last Name Current Title/Role Current Command Please answer question 1 (First Name) before continuing. Please answer question 1 (Last Name) before continuing. Please answer question 1 (Current Title/Role) before continuing. Please answer question 1 (Current Command) before continuing. Please select your Rank Please answer question 11 before continuing. Please select your Corps Please answer question 10 before continuing. 2. Please provide the contact information requested below. Due to the health.mil email transition concerns, we encourage you to list a secondary email in the box provided. Primary Email Secondary Email Primary Phone Number Secondary Phone Number Please answer question 2 (Primary Email) before continuing. Your answer to question 2 (Primary Phone Number) must be a valid International Phone Number Your answer to question 2 (Secondary Phone Number) must be a valid International Phone Number 3. Please provide a brief description of your role within your command and any secondary responsibilities you feel would be relevant to your application. Please answer question 3 before continuing. Statement of Interest* 4. In 200 words or less, please describe why you are interested in QSLA, what you hope to gain from the program, and how you plan to use the HRO skills and knowledge acquired during the program in your current and/or future role. Please answer question 4 before continuing. Participant Availability and Commitment 5. Two NMQSLA Cohorts are being planned to occur throughout CY 2024. Both Cohorts will feature a hybrid Kick-Off (approximately one week) and subsequent Virtual Classrooms (~20 to 25 hours over the course of three months). From the following options, *please indicate which of the Cohort options you would be able to attend. Final Scholars will only be selected for one Cohort.** If you cannot attend one of the Cohort options due to a prior scheduling commitment, please specify your schedule conflict for that timeframe. DISCLAIMER: Please note that travel funding to attend NMQSLA will be determined once Scholars have been selected, and may be required to be Command-funded. Additionally, the dates listed are NOT final and are subject to change. Additional guidance on travel booking and Kick-Off logistics will be provided to confirmed Scholars. Any additional concerns pertaining to the in-person Kick-Off may be referred to the NMQSLA Support Team Mailbox. I can attend the Pacific Cohort,* Spring 2024; Kick-Off tentatively scheduled for March 18 to 22 with Virtual Classrooms and Tabletop Exercises occurring intermittently from March to June 2023. I can attend the Atlantic Cohort, Summer 2024; Kick-Off tentatively scheduled for June 3 to June 7 with Virtual Classrooms and Tabletop Exercises occurring intermittently from June to September 2023. I can NOT attend the Pacific Cohort option I can NOT attend the Atlantic Cohort option Please answer question 5 before continuing. Please select at least 1 choices for question 5. 6. Please indicate if you are anticipating a permanent change of station (PCS) during the NMQSLA timeframe; if so, please note your anticipated Command and Title. I will be PCS'ing during the QSLA timeframe I will NOT be PCS'ing during the QSLA timeframe Please answer question 6 before continuing. 7. I have informed my Chain of Command leadership of my application and intent to participate in NMQSLA, and confirm their support for my participation. YES NO Please answer question 7 before continuing. 8. If selected, I commit to attending 100% of the week-long in-person Kick-Off and at least 80% of the Virtual Classroom sessions (~20-25hrs over the course of three months) following the program Kick-Off. YES NO Please answer question 8 before continuing. Program Awareness 9. How did you hear about NMQSLA? Please note how you became familiar with the program below. 100% Complete Powered by Verint: Experience Management - Verint