http://www.bettycjung.net/Phenomlogf.htm

Public Health Expertise Network of Mentors Program
On-line Contact Log Form

Welcome to the P.H.E.N.O.M. Online Mentor Contact Log Form!

Your input is appreciated!

Just complete this form. Click on Submit when ready to send.

FOR THE ACADEMIC YEAR OF SEPTEMBER, 2011 - AUGUST, 2012

Directions: Complete this form for EACH contact. This form allows you to log in one contact at a time. Use this form as many times as you need. Fill in Date, Length of Contact, Location, Content, and choose the appropriate items, using the dropdown menus:

NAME OF MENTOR:

CONTACT DATE (i.e., MM/DD/YYYY):

HOW WERE YOU CONTACTED?

CONTACTED BY:
If other, who?

HOW DID THEY HEAR ABOUT THE PROGRAM?
If other, who?

LENGTH (MINS):

ACTIVITY

GEOGRAPHIC INFO (Town, if CT; State, if not CT; Country if not US)

CONTENT:

QUESTIONS, COMMENTS, ETC. :

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Published on the Web: June 12, 2000; February 21, 2001
UPDATED: November 27, 2011 R70
Comments, suggestions, dead link reports: Betty C. Jung, Webmaster

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© Copyright 1999 - 2012 Betty C. Jung
All rights reserved.