Peer Mentor Report Form

Let us know about your connection with your mentee. Submit this form when the relationship with your mentee has ended.

Name

Email *

Name of mentee *

Mentee’s email address *

Did your mentee respond to you after three attempts to connect with them? *

• Yes
• No

What was the purpose of the connection? Select all that apply:

• Find specific resources
• Emotional support/connection
• Connect with someone who has a specific experience
• Financial assistance support
• Transplant questions
• Treatment/side effects questions
• Other (please explain)

What support or resources did you provide your mentee with?

How did you communicate with your mentee? (Select all that apply)

• Phone
• Email
• Other (please specify)

What was the length of the relationship with your mentee?

• 1 day
• 2-6 days
• 1 week
• 2-3 weeks
• 1 month
• 2 months
• 3 months
• 4-5 months
• 6 months
• Longer than 6 months

How many communications did you have with your mentee?

• 0 – mentee never responded
• 1-2
• 3-5
• 6-10
• 11-15
• More than 16

Submit