Skip to content

Mentor Application

1.Applicant Name(Required.)
2.With which fatality review program are you affiliated?(Required.)
3.Location(Required.)
4.Is this a local or a state-level team?(Required.)
5.If local, do you have programmatic support from a state agency?
6.How would you describe your fatality review catchment area?
7.If state, does your state program support local fatality review teams?
8.How long has your site had an established fatality review program?(Required.)
9.How long have you worked in fatality review programs?(Required.)
10.What roles have you held in fatality review?(Required.)
11.Select the program(s) you work with:(Required.)
12.Please provide an example of how your fatality review program has demonstrated leadership in the field of injury prevention or maternal and child health?(Required.)
13.How could a mentor have supported you as a new fatality review professional, and how do you hope to support others?(Required.)
14.Can you commit to joining monthly mentoring meetings and being responsive to your mentees for a year?(Required.)
To ensure you will be able to participate in this mentorship opportunity, we request a supervisor or leader who can approve your travel, acknowledging that you will be able to participate and accept the conference sponsorship(s) mentors will receive. If you are selected, the National Center will provide you with a form to be completed your supervisor or travel approver.
2 / 1
200%