Please complete the following survey to express interest in becoming a New York State Public Health Corps Fellowship Program (NYSPHC) Mentor. Mentors serve as professional role models and technical advisors to NYSPHC Fellows, facilitating their peer-learning and providing relevant mentoring, career planning and navigational support. The NYSPHC Fellowship Program will be utilizing a cohort style of mentoring with Mentors leading between 4-8 NYSPHC Fellows for up to two years with the expectation to meet on a quarterly basis.

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* 1. Name:

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* 2. Title:

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* 3. Organization Affiliation:

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* 4. Work Location:

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* 5. Professional Background & Interests:

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* 6. Resume (optional)

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* 7. Years of Experience in the public health field:

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* 8. Area of Expertise (select all that apply):

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* 9. How many Fellows would you like in your cohort (between 4-8)?

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* 10. Are you interested in co-leading a cohort?

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* 11. Availability/Commitment: Cohort Scheduling (Mentors are expected to meet quarterly with their cohort. However, cohorts can meet more frequently if desired. Mentors are encouraged to meet with their Fellows individually, as well)

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* 12. Availability/Commitment: Mentor Quarterly Check Ins (Mentors are expected to meet with NYSPHC staff and all other Mentors statewide twice a year for one hour)

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* 13. Availability/Commitment to attend NYSPHC events (Mentors are encouraged to attend other NYSPHC events such as Educational Series, Consortia, and the annual Summit)

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* 14. Do you have any recommendations for individuals who may be interested in being a NYSPHC Mentor?

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* 15. If yes, please provide the individual(s) names and email addresses. A NYSPHC Team member will contact them with additional information.

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