Form 1 Mentee Application and Competancy Assessment

Research to Reality Mentorship Program Mentee Application Insert Deadline Date Page | 6

OMB #: 0925-0046-11 Expiry Date: 2/28/2013

STATEMENT OF CONFIDENTIALITY

Collection of this information is authorized by The Public Health Service Act, Section 412 (42 USC 285 a-1). Rights of applicants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this application will be held in professional confidence. Names and other identifiers will be separated from information provided and will not appear in any report of the pilot program. Information provided will be combined for all applicants and report as statistical summaries.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 60 minutes per application, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046). Do not return the completed form to this address.

Completion and submission of this application implies consent for participation.

Mentee Application

NCI Research to Reality Mentorship Program

If you are interested in becoming a mentee in the Research to Reality Mentorship Program, please complete the following questions.

Name:
Title:
Degree(s):
Organization/Agency:
Street Address:
City:	State:		Zip:
Phone:		Fax:
Email:

Section 1: Prior Experience

In addition to submitting a resume/CV, please answer the following questions regarding your experience.

1. How much of your job involves planning or implementing health promotion or cancer control programs?

All (> 95%)
Most (65-95%)
About half (35-65%)

Some (< 35%)

Don’t Know/Prefer Not to Answer

2. In the last 12 months have you….

	Yes	No	Don’t know/Prefer Not to Answer
developed/implemented your own intervention?
implemented an intervention developed by someone else?
adapted an intervention someone else developed?
Evaluated an intervention developed by you or someone else?

3. Are/have you engaged in a comprehensive cancer control coalition in a state, tribe, territory, or US Jurisdiction, or at a local level?

Yes, currently Yes, in the past No, never

1. If yes, please briefly explain your involvement with the Cancer Control Planning and experience with Cancer Control Coalitions (at the State, Tribe, Territory, or US jurisdiction, or local level)

Section 2: Competency Assessment

Below are the six competency areas that the Mentorship Program will target. This competency assessment will help in the selection and matching of mentees with mentors.

1. Please rate your ability in the following competencies (1=none; 4=expert):

Competency	1	2	3	4
Analytic/Assessment Skills
Recognize how the data illuminate ethical, political, scientific, economic, and overall public health issues
Identify relevant and appropriate data information source
Make relevant inferences from data
Determine appropriate uses and limitations of both qualitative and quantitative data
Policy Development/Program Planning Skills
Collect, summarize, and interpret information relevant to an issue
Utilize current techniques in decision analysis and health planning
Develop a plan to implement policy, including goals, outcomes, and process objectives and implementation steps
Cultural Competency Skills
Apply principles of cultural appropriateness to program design
Interact sensitively and effectively with persons from diverse backgrounds
Identify role of cultural, social, and behavioral factors in determining delivery of public health services
Develop and adapt approaches to problems that take into account differences among populations
Public Health Science Skills
Apply basic public health sciences
Identify and retrieve current relevant scientific evidence
Identify the limitations of research and the importance of observations and interrelationships
Partnership, Collaboration, and Community Engagement Skills
Define a health issue according to the needs and assets of the population/community
Establish and maintain linkages and/or partnerships with key stakeholders (including traditional, nontraditional, and academic partners).
Evaluate expertise and resources, including partnerships and collaborations, needed to implement evidence-based cancer control interventions
Utilize negotiation and conflict resolution skills to build community partnerships
Advocacy and Communication Skills
Effectively present accurate demographic, statistical, programmatic, and scientific information for professional and lay audiences
Advocate for public health programs and resources
Identify policy options and write clear and concise policy statements

2. While it is hoped that through your participation you will improve your capacity in all six core competencies areas, mentees are asked to select at least two competency areas in which they want to prioritize their focus. Please indicate the competency area(s) on which you would like to focus (minimum of two):

Analytic/Assessment Skills

Policy Development/Program Planning Skills

Cultural Competency Skills

Basic Public Health Science Skills

Partnership, Collaboration, and Community Engagement Skills

Advocacy and Communication Skills

Section 3: Mentee Project and Mentoring

1. A component of this program is the completion of an individual project to learn and apply the skills you will gain through this experience. In a separate document, please briefly (< 500 words) describe your proposed project, including: how it meets the needs of your organization and fits in with your current work; how a mentor will be helpful; and how it will address your prioritized competency area (examples of sample projects can be found on the Mentorship webpage or in the program materials).

2. If you are accepted into the program, what, if any, specific traits/expertise of your mentor are important to you?

Section 4: Program Participation and Travel

Participation in all program activities is mandatory and certain activities will require travel. Please answer whether you will be able to meet these requirements below.

4.1 Does your organization permit you to travel in your position? (NOTE: Travel costs to be covered by NCI)

Yes

No

Comments:

4.2 The kick-off meeting will be held DATE TO BE INSERTED in Bethesda, MD. This is a required activity. Will you be able to attend?

Yes

No

Maybe

Section 5: Additional Information (optional)

To help us with evaluation of the pilot program, please answer the following question.

1. How did you hear about the mentorship program?

Email announcement

From a colleague

ResearchtoReality.cancer.gov

Other Web site __________________

Other __________________

Please send your application materials by email (preferred) or mail to:

Peyton Purcell, MPH

Research to Reality Mentorship Program Coordinator

6116 Executive Blvd., Room 4104

Bethesda, MD 20892

[email protected]

DEADLINE: Insert Deadline Date

Application Checklist: Did you remember to send….

Completed application form

Description of proposed project

Mentee/Supervisor agreement form

CV/Resume

F or questions or additional information about the Research to Reality Mentorship Program,
please contact Peyton Purcell ([email protected] or (301-594-9075).