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1. Name; E-mail

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2. If CHES or MCHES, provide your number

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3. Date of Contact

Date

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4. How were you contacted?

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5. Mentee geographic location

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6. If available, mentee demographics (age, gender,etc.)

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7. Length of contact (in minutes)

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8. Mentoriing Activity

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9. Describe the mentoring activity

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10. Questions, comments, etc.

T