D1 Mentor and Student Match Form

Part I will be completed by Mentor and will provide a description of the experiences available.

Part II will be completed by the Student. The student will describe their learning objectives and the reason that the experience is a good match for their professional goals.

Part III records the agreement of the Student and Mentor to work together on a specific project.

PART I Lab Description Student Name:

Mentor Christine Berg, PhD, OTR/L, FAOTA

Email address [email protected]

Phone number 286-1745

Description of 2 year projects: a student will focus on building capacity with a community agency. Students expand their clinical skill set focused around program development and community health education delivery. These experiences are individualized and tailored to a specific agency with whom the student will partner. Dr. Berg and the student will talk about available projects.

Expectations (time, lab hours, transportation needs, etc)  Attend a weekly meeting with all students involved in the community track. Students will be involved with 8 to 10 hours a week, inclusive of weekly 1-hour team meetings, literature review and ongoing writing.  Flexibility in scheduling is required, because of the community agency scheduling and programming.  A car is generally necessary for a community projects.

PART II Student Self-evaluation

List your learning objectives for working with Dr. Berg:

How will this experience help you achieve your professional goals? Describe your successful learning style and level of self-directedness:

Part III Mentorship Agreement

Student Name and Campus Address:

Title or Brief description of doctoral project (focus to be determined with student matched with a community agency interested in a program development focus)

Student Signature & Date:

Mentor Signature & Date:

*Original signatures required