Welcome to the School of Public Health Mentor Data application.

The School of Public Health Mentor Program provides an opportunity for students at the Master's and Ph.D. level to develop their professional skills outside of the classroom and begin to build a professional network.

Students and mentors are matched based on mutual interests and mentors' expertise. The mentor-student relationship is informal with monthly contact by phone, email, or in-person. It is also a great way for alumni and friends to connect with the school as well as current and future professionals in their field. Please read the expectations below to determine if you will be able to make the commitments needed to make the mentoring relationship a success.

Guidelines for the Mentor/Student Relationship:

1. Attendance at the Mentor Kick-Off event is highly recommended. This provides an opportunity to meet your student and other mentors and to learn more about the program. We recognize that some mentors have conferences or schedules that prevent their attendance. Please arrange to meet individually with your student if you are unable to attend the Kick-Off event.
2. Meet or communicate with your student once a month or as determined by the goals you set together.
3. When you meet your student, establish goals for the mentor relationship. Agree how often you plan to get together and discuss who will assume responsibility for arranging the meetings (which could be a shared responsibility). Because both mentors and graduate students have busy schedules, plan future meetings each time you meet.
4. Determine early in the year if your student is interested in job shadowing you or one of your colleagues. Attempt to set up shadowing as early as possible.
5. Contact your student and the Mentor Program (612-626-5536) if circumstances require you to discontinue your participation or if your student has not maintained contact.
6. The mentor relationship should comply with the professional code of conduct. Please return phone calls and email correspondence in a timely fashion.
7. Complete program evaluations when appropriate.

Please Note: The goal of the program is to expose graduate students to personal experiences in the field of public health and to establish professional relationships between students and mentors. Although a student's participation may lead to a possible internship or field experience, this is not an expectation of the mentor program.

By completing this form, I indicate my willingness to mentor a public health student for the 2011-12 academic year (from October 2011 through April 2012). I have read the above guidelines and understand my responsibilities as a mentor. I understand that I will receive more information about the student in October prior to the Mentor Kick-Off event.      Yes No

Fields marked with an asterisk (*) are required.

*First Name:      *Last Name:

Job Title:

Area(s) of Responsibility:

* Company / Employer:

Preferred Mailing Address line 1:

Preferred Mailing Address line 2:

Preferred Mailing Address line 3:

City:     State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, District of Columbia West Virginia Wisconsin Wyoming     Zip:

* Work Phone:      Home Phone:

* Preferred Email:

Best time/place/method (voicemail, email, etc) to reach you:

I give you my permission to share my contact information with mentors and students in this program.
Yes No

Fields marked with an asterisk (*) are required.

Have you participated in the SPH Mentor Program before?
Yes No

Are you an alumnus of the U of MN School of Public Health? (Being an alumnus is not required.)
Yes No

* Program Major: Please select the major that relates most closely to your professional interests and expertise to help us match you with a student.
Choose from the options below Biostatistics Clinical Research Community Health Promotion Environmental Health Epidemiology Executive MHA Program Global/International Health Policy and Administration,Health Services Research, Policy and Administration Healthcare Administration Maternal and Child Health Public Health Administration and Policy Public Health Nutrition Public Health Practice/Executive Veterinary Public Health Other

If other, please specify:

If you have a degree or degrees from another program or university, please specify:
Degree 1:
BA/BS MHA MPH MS PhD MBA MD RN RD JD SciD DrPH Other NA

Degree 1 - Major:

Degree 2:
BA/BS MHA MPH MS PhD MBA MD RN RD JD SciD DrPH Other NA

Degree 2 - Major:

Additional degree or certification, please specify:

Areas of Program Emphasis:

In order of importance, select up to four interests/areas of expertise to help us match you with a student.
Interest A:
--- Scroll to view complete list --- Administration Adolescent Health Aging and Long Term Care Alcohol Drug Tobacco Biostatistics Bioterrorism Cancer Epidemiology Chronic Disease Clinic Management Clinical Trials Community Health Promotion Community Organizing Consulting Data Analysis Environmental Health Epidemiology Evaluation Research Faculty / Academia Finance Food-borne Disease / Food Safety Genetic Epidemiology Grant Writing Health Planning Health Policy Health Promotions HIV / AIDS Industrial Hygiene Infectious Disease Insurance International Health Managed care Maternal / Child Health Medical device Minority Health / Underserved Populations Non-profit Organizations Nutrition Obesity Prevention Occupational Health Population Assessment Public Health Nursing Public Speaking / Presentations Refugee Health Reproductive Health Rural Health Sexual Education / STDs Toxicology Veterinary Health Other - Please specify in the space provided
Interest B:
--- Scroll to view complete list --- Administration Adolescent Health Aging and Long Term Care Alcohol Drug Tobacco Biostatistics Bioterrorism Cancer Epidemiology Chronic Disease Clinic Management Clinical Trials Community Health Promotion Community Organizing Consulting Data Analysis Environmental Health Epidemiology Evaluation Research Faculty / Academia Finance Food-borne Disease / Food Safety Genetic Epidemiology Grant Writing Health Planning Health Policy Health Promotions HIV / AIDS Industrial Hygiene Infectious Disease Insurance International Health Managed care Maternal / Child Health Medical device Minority Health / Underserved Populations Non-profit Organizations Nutrition Obesity Prevention Occupational Health Population Assessment Public Health Nursing Public Speaking / Presentations Refugee Health Reproductive Health Rural Health Sexual Education / STDs Toxicology Veterinary Health Other - Please specify in the space provided
Interest C:
--- Scroll to view complete list --- Administration Adolescent Health Aging and Long Term Care Alcohol Drug Tobacco Biostatistics Bioterrorism Cancer Epidemiology Chronic Disease Clinic Management Clinical Trials Community Health Promotion Community Organizing Consulting Data Analysis Environmental Health Epidemiology Evaluation Research Faculty / Academia Finance Food-borne Disease / Food Safety Genetic Epidemiology Grant Writing Health Planning Health Policy Health Promotions HIV / AIDS Industrial Hygiene Infectious Disease Insurance International Health Managed care Maternal / Child Health Medical device Minority Health / Underserved Populations Non-profit Organizations Nutrition Obesity Prevention Occupational Health Population Assessment Public Health Nursing Public Speaking / Presentations Refugee Health Reproductive Health Rural Health Sexual Education / STDs Toxicology Veterinary Health Other - Please specify in the space provided
Interest D:
--- Scroll to view complete list --- Administration Adolescent Health Aging and Long Term Care Alcohol Drug Tobacco Biostatistics Bioterrorism Cancer Epidemiology Chronic Disease Clinic Management Clinical Trials Community Health Promotion Community Organizing Consulting Data Analysis Environmental Health Epidemiology Evaluation Research Faculty / Academia Finance Food-borne Disease / Food Safety Genetic Epidemiology Grant Writing Health Planning Health Policy Health Promotions HIV / AIDS Industrial Hygiene Infectious Disease Insurance International Health Managed care Maternal / Child Health Medical device Minority Health / Underserved Populations Non-profit Organizations Nutrition Obesity Prevention Occupational Health Population Assessment Public Health Nursing Public Speaking / Presentations Refugee Health Reproductive Health Rural Health Sexual Education / STDs Toxicology Veterinary Health Other - Please specify in the space provided

If any of your choices were "other", please describe:

If you have specific interests that would help us in matching you with a student, please explain here:

What does being a mentor mean to you? What are your expectations for this program?

Are you a member of the Minnesota Public Health Association?
Yes No

In addition, I would be interested in the following (check all that apply):
Serving on an Advisory Committee for the School of Public Health Mentor Program
Speaking on a career panel
Serving as a network contact
Providing a job shadow experience for Public Health students
Providing a company / organization field placement or internship site
Speaking with prospective students interested in Public Health
Sponsoring a company information session for on-campus recruiting
Posting job / internship opportunities
Other

Specify other: