Mentor Network Activity Report

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* 1. First name:

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* 2. Last name:

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* 3. e-mail:

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* 4. What date did you visit a classroom or participate in another type of outreach event? (XX-YY-ZZZZ)

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* 5. Was this event DNA Day related (does not necessarily mean that it had to occur on 4/25 but perhaps you were recruited for a DNA Day related activity)?

Yes

No

Unsure

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* 6. How were you contacted about this outreach opportunity?

The teacher contacted me directly

I was contacted by ASHG directly

I found this opportunity myself through contacts/interest

Other (please specify)

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* 7. Who was your contact at the location you visited?

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* 8. What is their contact information (e-mail preferred):

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* 9. Name of institution (school, community center or other location where you performed the outreach).

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* 10. Address of institution (at least city, state):

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* 11. Please describe your experience. For example, what grade levels did you work with? How long were you there? Was the contact easy to work with? Etc.

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* 12. Did you bring materials with you (powerpoint, handout, activity, etc.)?

Yes

No

Other (please specify)

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* 13. If you answered yes to the previous question, would you be willing to share this resource with others in the Mentor Network? If you answer yes, we will contact you to gather this resource and determine if there is a way we can add this to a growing library of resources we are hoping to have available to mentors.

Yes

No

Other (please specify)

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* 14. We are grateful for your help in documenting the participation of mentors in the Mentor Network program. If you have specific comments, questions, concerns or suggestions for this program, we would appreciate hearing from you.