<p>D1 Mentor and Student Match Form</p><p>Part I will be completed by Mentor and will provide a description of the experiences available.</p><p>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.</p><p>Part III records the agreement of the Student and Mentor to work together on a specific project.</p><p>PART I Lab Description Student Name:</p><p>Mentor Christine Berg, PhD, OTR/L, FAOTA</p><p>Email address [email protected]</p><p>Phone number 286-1745</p><p>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. </p><p>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.</p><p>PART II Student Self-evaluation</p><p>List your learning objectives for working with Dr. Berg:</p><p>How will this experience help you achieve your professional goals? Describe your successful learning style and level of self-directedness:</p><p>Part III Mentorship Agreement</p><p>Student Name and Campus Address:</p><p>Title or Brief description of doctoral project (focus to be determined with student matched with a community agency interested in a program development focus)</p><p>Student Signature & Date: </p><p>Mentor Signature & Date: </p><p>*Original signatures required </p>