Monthly Report Form

Answer each of the following questions based on your contact with your mentee during the previous month. Please be precise in your reporting and provide as much relevant details as you can. Your responses are confidential and will not be shared with anyone outside of the program staff. The information provided will not be shared with your mentee. Please complete and turn in by the 5th working day of the month following the month for which you are reporting.

Select the month for which you are reporting contact with your mentee:

Select the year for which you are reporting contact with your mentee:

State:

Mentor Name:

Mentee Name:

Please estimate the total number of times that you and your mentee have communicated by phone?

Please estimate the total number of times that you and your mentee have communicated by email?

Please estimate the total number of times that you and your mentee have communicated by IM?

Please estimate the total number of times that you and your mentee have communicated in person?

Please estimate the total number of hours and minutes that you and your mentee have communicated during the past month. Use the guideline of one E-mail equals 5 minutes, and you may include the time spent at mentor/mentee scheduled events if you and your mentee were together. # Hours:

# Minutes:

On a scale of 1= low to 10= high, how would you characterize the depth/quality of communication between you and your mentee during the past month?

On a scale of 1= low to 10= high, how would you rate the current strength of the connection that you have with your mentee? In other words, how low or high would you rate the depth of trust, understanding and openness in your relationship today?

What, if any, have been barriers to you and your Mentee meeting by telephone, or in person? (1000 characters maximum)

Please note any additional positive or negative comments you have regarding your mentoring relationship to this point in the program. (1000 characters maximum)

Thank you for completing this report!