Thank you for agreeing to participate as a project preceptor/mentor for the MCHC/RISE-UP  &/or MCH-LEARN Program (Baltimore City).  
 
Your time and support are greatly appreciated! 
 
More information on mentoring opportunities may be found by visiting the website:  https://www.kennedykrieger.org/training/programs/center-for-excellence-in-public-health-leadership/mentoring-opportunities
Our funders request a signed Project Preceptor/Mentor Agreement that includes a project description, background information on years of experience, and area of focus from each of our project preceptor/mentors. Thank you in advance for providing this information.

DEFINITIONS:
Project Preceptor – A preceptor is an individual who provides direct oversight and supervision to scholar on their summer projects.  A project preceptor is the content mentor who guides the scholar in research, clinical, or advocacy activities.  A Project Preceptor is generally not involved in direct academic or career development. A preceptor may oversee one or multiple scholars.

Project Mentor-A mentor is an individual who is responsible for providing support, counseling, or encouragement related to academic, career, and professional development for the scholar during (and after) their assignment.  Mentors may be asked to write letters of recommendation or work with scholars on publications and projects following their formal participation in Center for Excellence in Public Health Leadership programs.

Mentor Coach – A mentor coach serves as academic and professional development mentor who may not necessarily have expertise in science, clinical, or advocacy areas. The mentor meets weekly with the scholar, however the Mentor Coach does not supervise or offer a research, clinical, or advocacy project for the scholar.  Mentor Coaches assist scholars in navigating their learning environment and developing the scholar's final presentation.
 
  
Project Preceptor/Mentor - A Project Preceptor/Mentor serves as BOTH Project Preceptor and Mentor.
 
Please note that the information collected in this survey has a dual purpose.  First, information you provide via this survey is required by the funding agency for program evaluation. Second, information you provide will be used for research purposes (i.e., to test hypotheses about the effectiveness of program curricula and activities) after receiving your permission.  

Participation in this research is voluntary. Your permission (or lack of permission) in this research will have no effect on your current or future relationship with the Center for Excellence in Public Health Leadership at Kennedy Krieger Institute. You may cancel your permission to use your information at anytime by contacting Dr. Harolyn Belcher (CenterforExcellenceNPH@kennedykrieger.org). Your cancellation will not affect information already collected. Only de-identified (or limited, e.g., including dates) data will be used in research publications. We will use the findings from this survey with other data, to evaluate and improve the program. This study has been reviewed and approved by the Johns Hopkins Medical Institutional Review Board [IRB00398423; Principal Investigator: Harolyn M.E. Belcher, MD, MHS]. If you have any questions regarding this survey study, please contact: Harolyn M.E. Belcher, MD, MHS Director, Center for Excellence in Public Health Leadership at Kennedy Krieger Institute 716 North Broadway Baltimore MD 21205 Office:(443) 923-5933 CenterforExcellenceNPH@kennedykrieger.org

Completing this Mentor Agreement Application does not guarantee that an undergraduate scholar will be matched with you on your proposed project. You will be notified as soon as possible regarding your mentor-scholar match.   THANK YOU for your time and interest in mentoring!


I agree that the information provided in this survey can be used for research in aggregate and de-identified (or limited, e.g., dates may be used) format.
 
Please self-identify your role with the MCHC/RISE-UP and/or [Baltimore only] MCH-LEARN scholars. I will be a: 
I will accept a scholar(s) from the following program(s) (check all that apply):
I am a MCHC/RISE-UP project preceptor/mentor for the:
The Mentor Agreement Form is the only source of demographic information about mentors in the MCHC/RISE-UP and MCH-LEARN Program. The CDC Annual Performance Report requests information on the demographic composition of the mentors. Demographic data are reported in aggregate, without identifiers. Data on the Mentor Agreement may be reviewed by federal funders and Kennedy Krieger program staff.
Sex
Race (Check all that apply)
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Ethnicity
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Describe your prior experience (check all that apply):
Years of Public Health Experience:
Degree(s) Earned (Select all that appply):
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Primary area of professional focus:
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Research / Program Interest:
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The MCHC/RISEUP and/or MCH-LEARN Experience Project will focus on the following track(s)

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Select the public health essentials related to this project.  Check all that apply:

How many scholars can you mentor this summer?

How frequently will you meet with the scholar(s) to discuss the project?

How many days per week would you like the scholar to be available at your site (check all that apply)?
What days of the week are best for the scholar to work at your site (check all that apply)?











Is there a secondary mentor/project preceptor?