Family Scholars Program
Supervisor Form—Family Scholar / 2014-2015

FAMILY SCHOLAR PROGRAM ◦ SUPERVISOR FORM

The Family Scholars Program (FSP) is a 10-month leadership development program for family leaders. Each applicant is required to submit an FSP Supervisor Scholar Form to be completed by their supervisor in their organization/program. Your responses to the questions in the form will be considered by the review committee during the selection of Family Scholars.

Note: After the form has been completed, return the form to the applicant. The applicant will submit this form as part of the application to AMCHP. If any forms are missing from an applicant’s package, it may result in their applicant packet not being reviewed. Only applications submitted by email will be reviewed. The deadline is close of business 5:00 pm Eastern Time, Thursday, August 7, 2014. Please email with any questions.

Applicant Name

Supervisor Contact Information

Name:
Title:
Degree and/or Credentials:
Mailing Address:
City, State, and Zip Code:
Office Phone:
Fax:
E-mail:

Instructions: Please complete the following questions regarding the Applicant. Provide your response in the area below each question. Use as much space as you need to address each question.

Q1. What potential roles and responsibilities could the nominee fulfill for the organization/program by participating in the FSP? Please place an X in the column to the left of the potential activities in your program. Check all that apply. If not listed, list ideas for potential involvement under Other.
Provide a family perspective (via materials review, attend program meetings, or other avenues) / Improve planning and policies resulting in services more directly responsive to family needs
Engage in the needs assessment process / Improve understanding of programs by legislature, state officials, and the public
Review your agencies block grant / Increase parent/professional communication and understanding
Participate on advisory committees / Increase availability of family members able to participate in training, public awareness, and policy development
Engage and/or increase family involvement in Title V programs / Establish or strengthen base for a strong coalition for change within a program
Develop family specific tools and/or resources for a particular program / Increase responsiveness to Federal requirements
Raise awareness and understanding of family issues and needs / Provide direct, non-medical services, information or support to families
Encourage or facilitate collaboration between families/family organizations and Title V programs / Develop programs for families
Supervise other family members or staff employed.
Other:
Q2. How would you like this nominee to benefit by participating in the FSP? Please check all that apply. If not represented, please list items under Other.
Broaden their network / Have a better understanding of the MCH (big) picture
Understand emerging issues from the national level / Develop/increase skill level in the MCH Leadership Skills
Obtain a comprehensive view of Title V/breadth / Understand national scope of MCH/CYSHCN/Title V
Develop a cadre of MCH (family) champions / Understand their part in Title V
Develop skills to act as a liaison for family input and/or engage families / Other:

Q3. Does the applicant have a current role and associated responsibilities with a Title V program? If so, please describe them.

A3:

Q4. How does the organization/program intend to support the nominee? (e.g., engage as the AMCHP Family Delegate, engage them in Title V training, provide time to engage on relevant calls, create opportunities to present to staff and families, etc.)

A4:

Q5. What expectations do you have of the applicant if selected as an AMCHP Family Scholar?

Q5:

Q6: Based on your experience with the Applicant, how would you rate the Applicant on their ability to be a successful family scholar (based on criteria such as their ability to seek advice from another person and willingness to learn; ability to establish/expand their professional network; comfort in sharing needs and goals openly; openness to risk-taking and honest feedback; willingness to stretch themselves; demonstration of a successful track record of follow-through).

Excellent
□ / Good
□ / Satisfactory
□ / Poor
□ / Cannot Assess
□

Supervisor’s Support Statement

I have read the expectations related to the program and the Commitment Form. I am aware of the program dates of September 2014 through June 2015, responsibilities, and expectations and I nominate ______[applicant’s name] as a candidate for my state/territory as an AMCHP Family Scholar.

This individual is employed through a program supported by Title V / MCH Block Grant funds. If applicable, I agree to permit ______[applicant’s name] to take time from regularly assigned duties to participate in all sessions of the 10 month Family Scholars Program.

If applicable, I, ______, [Supervisor’s name], agree to support the applicant’s participation in FSP. I have discussed this leadership development opportunity with appropriate organization/agency managers. We have agreed to actively support the applicant’s learning experience and project activities if he or she is selected to participate in the program through a variety of ways (e.g. – using work time to participate on monthly calls {group calls, individual mentor calls, quarterly group mentee calls} and/or complete stretch assignments that relate to their work activities).

I have reviewed the FSP program requirements and commitment form. The applicant has my support to participate in 6 – 12 hours per month in the FSP.

If the applicant is selected to participate in the program, I agree to complete a brief assessment of the applicant related to the MCH Leadership Competencies.

My typed name below indicates that I support the application for this individual to the AMCHP Family Scholars Program.

______

Supervisor’s Signature Date

For more information about the Family Scholars Program visit the AMCHP Web site (www.amchp.org).

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