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Mentee Application
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1.
Applicant name
(Required.)
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2.
With which fatality review program are you affiliated?
(Required.)
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3.
Location
(Required.)
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4.
Is this a local or a state-level team?
(Required.)
Local
State
5.
If local, do you have programmatic support from a state agency?
Yes
No
6.
How would you describe your fatality review catchment area?
Urban
Rural
Frontier
Border
Tribal
7.
If state, does your state program support local fatality review teams?
Yes
No
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8.
For how long has your site had an established fatality review program?
(Required.)
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9.
How long have you worked in fatality review programs?
(Required.)
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10.
What roles have you held in fatality review?
(Required.)
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11.
Select the program(s) you work with:
(Required.)
Child Death Review (CDR)
Fetal and Infant Mortality Review (FIMR)
Both CDR and FIMR
Maternal Mortality Review
Overdose Fatality Review
Suicide Fatality Review
Other (please specify)
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12.
What specific skills or aspects of your fatality review program do you hope will benefit from this mentorship opportunity and how?
(Required.)
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13.
Can you commit to joining monthly mentoring meetings for a six-month timeframe?
(Required.)
Yes
No