NEW DIRECTOR MENTOR PROGRAM

MENTOR APPLICATION

Thank you for your interest in serving as a potential mentor to a new Title V MCH/CYSHCN Director. To assist AMCHP make a good match between you and a new director we would like to know more about your state and your experience. The information will help us pair individuals that have similar program responsibilities, state structure, and experience dealing with similar challenges. Please email or fax your application to Librada Estrada at or fax #: 202-775-0061.

Name and Address Information

Full Name:

Degree(s) Completed:

Position Title:

Do you oversee:  MCH programs onlyCSHCN programs only  Both

Organization:

Address:

City, State, Zip:

Phone:

Fax:

Email:

*Sex:

Female / Male

*Ethnicity:

Hispanic or Latino / Not Hispanic or Latino

*Race (check all that apply):

American Indian or Alaskan Native / Native Hawaiian/ Pacific Islander
Asian / White
Black or African American / Other Race: ______

*The information will only be used for aggregate purposes.

Years of Experience

A. How long have you served as the MCH and/or CSHCN director for your state (please select one)?

5 years
6-10 years
11-15 years
16-20 years
21-25 years

B. Have you previously been a state Title V, MCH and/or CSHCN director in another state?

Yes / If yes, how long did you serve and where? ______
No

Program Areas

C. Which MCH/CSHCN or related programs/activities are within your administration or management responsibilities?
Check () all that apply even if only part of the program/activity is under your management.

Adolescent Health / Maternal Mortality Review
Birth Defects/Genetics / MCH Epidemiology
Breast & Cervical Cancer / MCH Surveillance (PRAMS, YRBS, Birth Defects Surveillance, etc.)
Childhood Injury Prevention/EMSC / Medical Home Program
Chronic Disease / Newborn Blood Spot Screening
Data Analysis/Epidemiology / Newborn Hearing Screening
Direct Care CSHCN Program / Oral Health
Domestic Violence (including rape crisis) / Program for Care Coordination and Financial Assistance
Early Childhood Comprehensive System / Reproductive Health (separate of Family Planning; e.g. STI and STD education, screening, treatment, etc.)
Early Intervention—Part C IDEA / Ryan White
Family Planning/Title X / Supplemental Security Income (SSI) Disabled Children’s Program
Immunization / Transition Program
Home Care Waiver Program / WIC (Women’s Infant and Children Nutrition Program)
Infant Mortality Reduction (including Healthy Start) / Women’s Health
Infant/Child Death Review / Other, specify:

D. Indicate from the following list the structure of your program.

Level of Service / Percentage / Comments
Infrastructure building
Population-based
Enabling services
Direct health care

E. What are your administrative responsibilities for these programs?

Contract management
Program/Policy development
Direct Services management
MCH Block Grant Administration
Other:

1

F. What are some major issues that have directly impacted your state’s MCH/CSHCN program that you have successfully dealt with in the last three years? (E.g. balancing direct service delivery and other core functions of public health, integrating MCH/CYSCHN services into the larger agency services, agency reorganization, program design to target populations, budget challenges)

1.

2.

3.

G. Are you familiar with AMCHP’s publication Leading State MCH Programs: A Guide for Senior Managers?

Yes
No, but I have a copy of the resource.
No I do not have a copy andwould like to have a copy emailed to me.

NOTE:Your responses for the following three items (H—J will be shared with the individual that is selected as a mentee).

  1. What would you like to gain by participating in this program?
  1. What expectations would you have of a mentee?
  1. Please insert (or send) your current BIO information below (one-page please).

1