Local Health Department Directors of Nursing Mentorship Program
Mentee Application Form
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1.
Full Name (First, Last):
(Required.)
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2.
Email:
(Required.)
*
3.
Phone Number:
(Required.)
*
4.
County:
(Required.)
Com
mitment:
*
5.
Are you committed to meeting with your mentor at least monthly for 6 months?
(Required.)
Yes
No
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6.
Are you committed to an attitude of learning by maintaining a positive mindset?
(Required.)
Yes
No
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7.
Are you committed to maintaining professionalism, and communicating with your mentor openly and honestly?
(Required.)
Yes
No
Experience:
8.
How many years of experience do you have as Director of Nursing in local public health?
9.
Please list other public health and nursing management experience: