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PHENOM Mentoring Activity Log
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Mentor Name; E-mail
Your answer
If CHES or MCHES provide your number
Your answer
Date of Contact
MM
/
DD
/
YYYY
How were you contacted?
Choose
Email
In-person
Online
Other
Mentee geographic location
Your answer
Mentee Age group (try and collect)
Choose
19 or under
20-29
30-39
40-49
50-59
60+
Gender
Choose
Female
Male
Other
Mentee Race/Ethnicity (Try to collect)
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American Indian or Alaska Native
Asian
Black
Hispanic/Latino
Middle Eastern/North African
Native Hawaiian or Other Pacific Islander
White
Other
Length of contact (in minutes)
Your answer
Describe what was covered during the mentoring activity.
Your answer
Submitted an article for the PHENOM Blog (Date,Title)
Your answer
Gave a presentation about career options, etc. Provide date, description, audience demographicsÂ
Your answer
Other mentoring activity - describe
Your answer
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