Peer Support Mentee 1 Year Evaluation

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* 1. Name

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* 2. In what state or U.S. territory do you currently work?

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* 3. Date started in Peer Support Program (month/year):

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* 4. Today's date:

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* 5. Your mentor's name:

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* 6. Have you and your mentor continued the mentoring relationship since you completed the 6-month evaluation?

Yes

Other (please specify) If yes, briefly describe the type of activities. If no, please explain why.

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* 7. As a result of the Peer Support Program, indicate the level of progress that you feel you have achieved for each of the Essential Services on which you focused.

	Considerable Progress	Some Progress	No Progress	Not Applicable
Assess and monitor the population's oral health status, factors that influence oral health, and community needs and assets.	Assess and monitor the population's oral health status, factors that influence oral health, and community needs and assets. Considerable Progress	Assess and monitor the population's oral health status, factors that influence oral health, and community needs and assets. Some Progress	Assess and monitor the population's oral health status, factors that influence oral health, and community needs and assets. No Progress	Assess and monitor the population's oral health status, factors that influence oral health, and community needs and assets. Not Applicable
Investigate, diagnose and address oral health problems and hazards affecting the population.	Investigate, diagnose and address oral health problems and hazards affecting the population. Considerable Progress	Investigate, diagnose and address oral health problems and hazards affecting the population. Some Progress	Investigate, diagnose and address oral health problems and hazards affecting the population. No Progress	Investigate, diagnose and address oral health problems and hazards affecting the population. Not Applicable
Communicate effectively to inform and educate people about oral health and influencing factors and educate/impower them to achieve and maintain optimal oral health.	Communicate effectively to inform and educate people about oral health and influencing factors and educate/impower them to achieve and maintain optimal oral health. Considerable Progress	Communicate effectively to inform and educate people about oral health and influencing factors and educate/impower them to achieve and maintain optimal oral health. Some Progress	Communicate effectively to inform and educate people about oral health and influencing factors and educate/impower them to achieve and maintain optimal oral health. No Progress	Communicate effectively to inform and educate people about oral health and influencing factors and educate/impower them to achieve and maintain optimal oral health. Not Applicable
Mobilize community partners to leverage resources and advocate for/act on oral health issues.	Mobilize community partners to leverage resources and advocate for/act on oral health issues. Considerable Progress	Mobilize community partners to leverage resources and advocate for/act on oral health issues. Some Progress	Mobilize community partners to leverage resources and advocate for/act on oral health issues. No Progress	Mobilize community partners to leverage resources and advocate for/act on oral health issues. Not Applicable
Develop, champion and implement policies, laws and systemic plans that support state, territory and community oral health efforts.	Develop, champion and implement policies, laws and systemic plans that support state, territory and community oral health efforts. Considerable Progress	Develop, champion and implement policies, laws and systemic plans that support state, territory and community oral health efforts. Some Progress	Develop, champion and implement policies, laws and systemic plans that support state, territory and community oral health efforts. No Progress	Develop, champion and implement policies, laws and systemic plans that support state, territory and community oral health efforts. Not Applicable
Review, educate about and enforce laws and regulations that promote oral health and ensure safe oral health practices.	Review, educate about and enforce laws and regulations that promote oral health and ensure safe oral health practices. Considerable Progress	Review, educate about and enforce laws and regulations that promote oral health and ensure safe oral health practices. Some Progress	Review, educate about and enforce laws and regulations that promote oral health and ensure safe oral health practices. No Progress	Review, educate about and enforce laws and regulations that promote oral health and ensure safe oral health practices. Not Applicable
Reduce barriers to care and assure access to and use of personal and population-based oral health services.	Reduce barriers to care and assure access to and use of personal and population-based oral health services. Considerable Progress	Reduce barriers to care and assure access to and use of personal and population-based oral health services. Some Progress	Reduce barriers to care and assure access to and use of personal and population-based oral health services. No Progress	Reduce barriers to care and assure access to and use of personal and population-based oral health services. Not Applicable
Assure an adequate, culturally competent and skilled public and private oral health workforce.	Assure an adequate, culturally competent and skilled public and private oral health workforce. Considerable Progress	Assure an adequate, culturally competent and skilled public and private oral health workforce. Some Progress	Assure an adequate, culturally competent and skilled public and private oral health workforce. No Progress	Assure an adequate, culturally competent and skilled public and private oral health workforce. Not Applicable
Improve and innovate dental public health functions through ongoing evaluation, research and continuous quality improvement.	Improve and innovate dental public health functions through ongoing evaluation, research and continuous quality improvement. Considerable Progress	Improve and innovate dental public health functions through ongoing evaluation, research and continuous quality improvement. Some Progress	Improve and innovate dental public health functions through ongoing evaluation, research and continuous quality improvement. No Progress	Improve and innovate dental public health functions through ongoing evaluation, research and continuous quality improvement. Not Applicable
Build and maintain a strong organizational infrastructure for dental public health.	Build and maintain a strong organizational infrastructure for dental public health. Considerable Progress	Build and maintain a strong organizational infrastructure for dental public health. Some Progress	Build and maintain a strong organizational infrastructure for dental public health. No Progress	Build and maintain a strong organizational infrastructure for dental public health. Not Applicable

Other (please specify) Provide examples of some successes.

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* 8. As a result of the Peer Support Program, indicate the level of progress you have achieved for each of the Competencies Guiding Principals on which you focused.

	Considerable Progress	Some Progress	No Progress	Not Applicable
Integrating oral health and general health	Integrating oral health and general health Considerable Progress	Integrating oral health and general health Some Progress	Integrating oral health and general health No Progress	Integrating oral health and general health Not Applicable
Programming for all life stages (lifespan approach)	Programming for all life stages (lifespan approach) Considerable Progress	Programming for all life stages (lifespan approach) Some Progress	Programming for all life stages (lifespan approach) No Progress	Programming for all life stages (lifespan approach) Not Applicable
Recognizing and reducing oral health disparities	Recognizing and reducing oral health disparities Considerable Progress	Recognizing and reducing oral health disparities Some Progress	Recognizing and reducing oral health disparities No Progress	Recognizing and reducing oral health disparities Not Applicable
Identifying, leveraging and using resources	Identifying, leveraging and using resources Considerable Progress	Identifying, leveraging and using resources Some Progress	Identifying, leveraging and using resources No Progress	Identifying, leveraging and using resources Not Applicable
Social responsibility to advocate for/serve underserved populations	Social responsibility to advocate for/serve underserved populations Considerable Progress	Social responsibility to advocate for/serve underserved populations Some Progress	Social responsibility to advocate for/serve underserved populations No Progress	Social responsibility to advocate for/serve underserved populations Not Applicable
Demonstrating an understanding and respect for other professions, their goals and roles	Demonstrating an understanding and respect for other professions, their goals and roles Considerable Progress	Demonstrating an understanding and respect for other professions, their goals and roles Some Progress	Demonstrating an understanding and respect for other professions, their goals and roles No Progress	Demonstrating an understanding and respect for other professions, their goals and roles Not Applicable
Respecting diversity and attaining cultural competency, including fostering health literacy	Respecting diversity and attaining cultural competency, including fostering health literacy Considerable Progress	Respecting diversity and attaining cultural competency, including fostering health literacy Some Progress	Respecting diversity and attaining cultural competency, including fostering health literacy No Progress	Respecting diversity and attaining cultural competency, including fostering health literacy Not Applicable
Dedication to lifelong learning and quality improvement	Dedication to lifelong learning and quality improvement Considerable Progress	Dedication to lifelong learning and quality improvement Some Progress	Dedication to lifelong learning and quality improvement No Progress	Dedication to lifelong learning and quality improvement Not Applicable

Other (please specify) Provide examples of some successes.

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* 9. As a result of the Peer Support Program, indicate the level of progress you have achieved for each of the Competency Domains on which you focused.

	Considerable Progress	Some Progress	No Progress	Not Applicable
Build Support for Collective Impact	Build Support for Collective Impact Considerable Progress	Build Support for Collective Impact Some Progress	Build Support for Collective Impact No Progress	Build Support for Collective Impact Not Applicable
Collect, Analyze and Summarize Data	Collect, Analyze and Summarize Data Considerable Progress	Collect, Analyze and Summarize Data Some Progress	Collect, Analyze and Summarize Data No Progress	Collect, Analyze and Summarize Data Not Applicable
Assess, Plan, Implement and Evaluate Programs	Assess, Plan, Implement and Evaluate Programs Considerable Progress	Assess, Plan, Implement and Evaluate Programs Some Progress	Assess, Plan, Implement and Evaluate Programs No Progress	Assess, Plan, Implement and Evaluate Programs Not Applicable
Recruit and Retain a Competent and Adequate Workforce	Recruit and Retain a Competent and Adequate Workforce Considerable Progress	Recruit and Retain a Competent and Adequate Workforce Some Progress	Recruit and Retain a Competent and Adequate Workforce No Progress	Recruit and Retain a Competent and Adequate Workforce Not Applicable
Assure Support for Programs	Assure Support for Programs Considerable Progress	Assure Support for Programs Some Progress	Assure Support for Programs No Progress	Assure Support for Programs Not Applicable
Use Public Health and Dental Public Health Science	Use Public Health and Dental Public Health Science Considerable Progress	Use Public Health and Dental Public Health Science Some Progress	Use Public Health and Dental Public Health Science No Progress	Use Public Health and Dental Public Health Science Not Applicable
Lead Strategically	Lead Strategically Considerable Progress	Lead Strategically Some Progress	Lead Strategically No Progress	Lead Strategically Not Applicable

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* 10. As a result of the Peer Support Program, did you make any specific changes or improvements to your state/territorial program, staffing or processes?

Yes

Other (please specify) If yes, briefly describe the changes you made and any outcomes.

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* 11. Did you experience any barriers that impacted your experience in the Peer Support Program?

Yes

Other (please specify) If yes, please provide details of the barriers encountered. Is there something ASTDD could do to assist you with overcoming this/these barriers?

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* 12. Are you involved with any ASTDD committees or work groups? (Check all that apply.)

Communications Committee

Dental Public Health Policy Committee

Fluorides Committee

Healthy Aging Committee

Perinatal Oral Health Committee

School and Adolescent Oral Health Committee

Other (please specify) Please list any other ASTDD work group or Community of Practice you are involved with:

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* 13. If you are not currently serving on any ASTDD committees or work groups, which would you be interested in joining? (Check all that apply.)

Communications Committee

Dental Public Health Policy Committee

Fluorides Committee

Healthy Aging Committee

Perinatal Oral Health Committee

School and Adolescent Oral Health Committee

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* 14. We would appreciate any other comments or suggestions for improving this program.

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* 15. Would you be interested in mentoring a new state dental director/oral health program manager in the future?

Yes

Maybe