Resident Grant Mentor Form
Please provide the following information:
Applicant’s name: ___________________________________________________________________
Institution name:___________________ ______________________________________
Institution location (city/state): ______________________________________________
Proposed project title: ____________________________________________________
Proposed project objectives:
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
Mentor’s name: _________________________________________________________
Mentor’s institution (if applicable):___________________________________________
Mentor’s address: ________________________________________________________
________________________________________________________
________________________________________________________
Mentor’s phone number: ___________________________________________________
Mentor’s email address: ___________________________________________________
Mentor’s Statement:
Please describe your plans for interacting with the applicant during the project; eg, frequency of meetings and
specific assistance you will provide. Please be aware Institutional Review Board (IRB) approval may be required
by your institution for the CATCH grant.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________
Please state your agreement to serve as a mentor for this applicant:
I have met with this applicant and we have discussed the project described in this application. I understand that this project should be
completed approximately 6 months after funding is received. I have reviewed the “Role of the Mentor” below. This statement
indicates my agreement to guide and assist the applicant with the timely completion of this project as outlined in the project
description above.
Name and Title: ____________________________________________________
Signature: ________________________________________________________
Date: _____________________________________________________________
Role of a Mentor
Mentors are a very important part of the resident CATCH project and are vital to the completion of the project
for residents. Mentors provide support and wisdom to the resident as they develop their community pediatrics
skills. Mentors can help the resident in a variety of ways. The following are some of the ways a mentor should
ASSIST the resident CATCH grantee to:
-
Develop their project
Assess community need for their project
Complete their CATCH application
Determine whether or not IRB approval will be required for the project
Complete the IRB application if needed or to find someone at the institution to help the resident
complete the application in a time-efficient manner
Complete their project during their residency, including regular meetings to help the resident to stay on
track with their projects
Develop community partnerships during the planning and implementation of their project to help make
their project a success
Apply for other sources of funding if necessary
Complete the CATCH final report at the conclusion of their project