Peer Support Mentee 1 Year Evaluation
Peer Support Mentee 1 Year Evaluation
*
1.
Name
(Required.)
*
2.
In what state or U.S. territory do you currently work?
(Required.)
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
3.
Date started in Peer Support Program (month/year):
*
4.
Today's date:
(Required.)
*
5.
Your mentor's name:
(Required.)
6.
Have you and your mentor continued the mentoring relationship since you completed the 6-month evaluation?
Yes
No
Other (please specify) If yes, briefly describe the type of activities. If no, please explain why.
7.
As a result of the Peer Support Program, indicate the level of progress that you feel you have achieved for each of the Essential Services on which you focused.
Considerable Progress
Some Progress
No Progress
Not Applicable
Assess and monitor the population's oral health status, factors that influence oral health, and community needs and assets.
Considerable Progress
Some Progress
No Progress
Not Applicable
Investigate, diagnose and address oral health problems and hazards affecting the population.
Considerable Progress
Some Progress
No Progress
Not Applicable
Communicate effectively to inform and educate people about oral health and influencing factors and educate/impower them to achieve and maintain optimal oral health.
Considerable Progress
Some Progress
No Progress
Not Applicable
Mobilize community partners to leverage resources and advocate for/act on oral health issues.
Considerable Progress
Some Progress
No Progress
Not Applicable
Develop, champion and implement policies, laws and systemic plans that support state, territory and community oral health efforts.
Considerable Progress
Some Progress
No Progress
Not Applicable
Review, educate about and enforce laws and regulations that promote oral health and ensure safe oral health practices.
Considerable Progress
Some Progress
No Progress
Not Applicable
Reduce barriers to care and assure access to and use of personal and population-based oral health services.
Considerable Progress
Some Progress
No Progress
Not Applicable
Assure an adequate, culturally competent and skilled public and private oral health workforce.
Considerable Progress
Some Progress
No Progress
Not Applicable
Improve and innovate dental public health functions through ongoing evaluation, research and continuous quality improvement.
Considerable Progress
Some Progress
No Progress
Not Applicable
Build and maintain a strong organizational infrastructure for dental public health.
Considerable Progress
Some Progress
No Progress
Not Applicable
Other (please specify) Provide examples of some successes.
8.
As a result of the Peer Support Program, indicate the level of progress you have achieved for each of the Competencies Guiding Principals on which you focused.
Considerable Progress
Some Progress
No Progress
Not Applicable
Integrating oral health and general health
Considerable Progress
Some Progress
No Progress
Not Applicable
Programming for all life stages (lifespan approach)
Considerable Progress
Some Progress
No Progress
Not Applicable
Recognizing and reducing oral health disparities
Considerable Progress
Some Progress
No Progress
Not Applicable
Identifying, leveraging and using resources
Considerable Progress
Some Progress
No Progress
Not Applicable
Social responsibility to advocate for/serve underserved populations
Considerable Progress
Some Progress
No Progress
Not Applicable
Demonstrating an understanding and respect for other professions, their goals and roles
Considerable Progress
Some Progress
No Progress
Not Applicable
Respecting diversity and attaining cultural competency, including fostering health literacy
Considerable Progress
Some Progress
No Progress
Not Applicable
Dedication to lifelong learning and quality improvement
Considerable Progress
Some Progress
No Progress
Not Applicable
Other (please specify) Provide examples of some successes.
9.
As a result of the Peer Support Program, indicate the level of progress you have achieved for each of the Competency Domains on which you focused.
Considerable Progress
Some Progress
No Progress
Not Applicable
Build Support for Collective Impact
Considerable Progress
Some Progress
No Progress
Not Applicable
Collect, Analyze and Summarize Data
Considerable Progress
Some Progress
No Progress
Not Applicable
Assess, Plan, Implement and Evaluate Programs
Considerable Progress
Some Progress
No Progress
Not Applicable
Recruit and Retain a Competent and Adequate Workforce
Considerable Progress
Some Progress
No Progress
Not Applicable
Assure Support for Programs
Considerable Progress
Some Progress
No Progress
Not Applicable
Use Public Health and Dental Public Health Science
Considerable Progress
Some Progress
No Progress
Not Applicable
Lead Strategically
Considerable Progress
Some Progress
No Progress
Not Applicable
10.
As a result of the Peer Support Program, did you make any specific changes or improvements to your state/territorial program, staffing or processes?
Yes
No
Other (please specify) If yes, briefly describe the changes you made and any outcomes.
11.
Did you experience any barriers that impacted your experience in the Peer Support Program?
Yes
No
Other (please specify) If yes, please provide details of the barriers encountered. Is there something ASTDD could do to assist you with overcoming this/these barriers?
12.
Are you involved with any ASTDD committees or work groups? (Check all that apply.)
Communications Committee
Dental Public Health Policy Committee
Fluorides Committee
Healthy Aging Committee
Perinatal Oral Health Committee
School and Adolescent Oral Health Committee
Other (please specify) Please list any other ASTDD work group or Community of Practice you are involved with:
13.
If you are not currently serving on any ASTDD committees or work groups, which would you be interested in joining? (Check all that apply.)
Communications Committee
Dental Public Health Policy Committee
Fluorides Committee
Healthy Aging Committee
Perinatal Oral Health Committee
School and Adolescent Oral Health Committee
14.
We would appreciate any other comments or suggestions for improving this program.
15.
Would you be interested in mentoring a new state dental director/oral health program manager in the future?
Yes
Maybe
No
Current Progress,
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