National Mentorship Program in
Applied Chronic Disease Epidemiology
2015 Cohort

Mentee Application

Section 1: General Information

First Name: / Last Name:
Degree(s):
Official Title:
Functional Title (if different):
Agency Name:
Agency Type (please check one): State Territory Local
(Note: If local, a letter of support from your state health agency is required)
Agency Street Address:
City: / State: / Zip:
Phone: / Fax: / Email:

Section 2: Education and relevant Work Experience (or attach a current CV or resume)

Please check if CV is attached to application and skip to Section #3: 

Formal Educational Background:

Year / Institution / Department / Degree

Other Work-Related Training:

Year / Institution / Program

Prior Work Experience:

Date From - To / Employer / Position or Title

Section 3: Self-Assessment of Competencies and Skills

An objective self-assessment of the applicant’s current competencies and skills is requested. Please rate your level of competency and skill for each item listed below, in regard to your current job capacity as a chronic disease epidemiologist.

Competencies and Skills

1. Planning / High / Moderate / Low / N/A
Time management
Prioritization
Multi-tasking
Setting goals and objectives
2. Analytic Knowledge
Mathematical
Scientific research process
Measurement
3. Communication
Verbal
Written
Visual (graphics)
Listening
Advocacy
Mediation
4. Basic Public Health Sciences
Public health principles
Chronic diseases
5. Informatics and Computer Knowledge
Data collection
Data management
6. Cultural Diversity
Consideration of cultural differences
Acceptance or understanding of diversity
7.Evaluation
Design and implement evaluations
Analysis and interpretation of data
Application of evaluation results

Duration of Mentorship

Applicants are asked to estimate the length of time that they would like for their mentoring experience. The maximum period cannot exceed twelve (12) months.

Anticipated Start Date: / Anticipated Duration:
% Effort :

Time to be devoted to the Mentoring Program: Applicants are asked to estimate the % effort they are able and willing to commit to the mentoring experience and competency development. This effort should include time spent for direct mentoring contact, as well as completion of projects and other tasks. The expected range is 20%-40%.

Section 4: Description of the Desired Mentorship Program

Targeted Competencies, Skills, and Projects:

Please provide a one-page description of the competencies and skills to be developed during the mentorship program and a brief description of the project around which these efforts will be focused. It is generally recommended that the mentoring effort be focused on a single target competency, selected from the seven described below.

  1. Planning Competency

Planning skills include time management, prioritization, multi-tasking and setting goals and objectives. These skills are involved in activities such as setting time and resource priorities that balance personal and organizational needs, and making decisions and initiating actions after careful consideration of pertinent data and possible consequences.

  1. Analytic Knowledge Competency

Application of sound scientific principles, critical thinking, and interpretive powers to attach meaning and significance to research are encompassed within the Analytic Knowledge competency. Specific skills within this competency include mathematical, scientific/ research process, and measurement/ evaluation design. These skills can be demonstrated during the design and conduct of scientific investigations, as well as during literature reviews, and the appropriate assessment and use of data sources.

  1. Communication Competency

Specific skills within the Communication competency include verbal, written/ visual, listening, and advocacy/ mediation. One aspect of these communication skills involves translation of scientific findings and haring of scientific knowledge in a way that is accurate, clear, concise, logical and appropriate for the target audience. Communication skills also involve relationship building both with co-workers and with community partners.

  1. Basic Public Health Sciences/ Core Functions Competency

Chronic disease epidemiologists are expected to have competency in the area of basic public health sciences and in their understanding of the core functions of public health services. Specific skills within this competency for chronic disease 6

E. Informatics/ Computer Knowledge Competency

Because epidemiologists are frequently involved in data-related tasks, computer and software knowledge are a key competency. Specific skills within this competency include data collection, data management, and data analysis.

F. Cultural Diversity Competency

Cultural diversity knowledge is an essential competency for all chronic disease program staff. Competency in this area is reflected through the adaptation and development of chronic disease programs that consider cultural differences, and the promotion of acceptance and understanding of diversity within program staff.

G. Evaluation Competency

Effective evaluation involves epidemiologists early in the planning stages. Competency in this area is reflected through the ability to: (a) design, implement, and coordinate scientifically sound evaluations of the health programs and policies; (b) assist program managers and decision-makers by providing information on using evaluation results to increase the effectiveness of existing programs and to design new programs that address identified needs; and (c) perform evaluation research activities including the analysis and interpretation of data about program impacts, using both qualitative and quantitative methods.

Section 5: Capacity for Chronic Disease Epidemiology

Please provide a brief description (e.g, one-page) of the agency’s capacity for chronic disease epidemiology. Identify persons involved who are engaged in chronic disease epidemiology. Include a brief description of how the Mentorship Program is expected to impact chronic disease epidemiology capacity in your state. Applicants are welcome to provide capacity information from the 2009 National Assessment of Epidemiology Capacity conducted by the Council of State and Territorial Epidemiologists. See email announcement for a copy of this report.

Section 6: Agency Support

Please provide a letter from your immediate supervisor, a letter from the Chronic Disease Director (separate letter required if this is not your immediate supervisor) and a letter from either the State or Local Health Director, Officer or Deputy agreeing to the terms of the mentorship arrangement and indicating support for the applicant’s intention to use the mentorship to enhance his or her skills or competencies in the target competency in Section # 4 of this application.

In this letter please indicate that you:

  • accept the applicant’s stated time commitment; and
  • have read and agree to the terms described within the applicant’s application.

Section 7: Application Submission Instructions

Please combine and save the completed application and required documentsas one PDF file or zipped (compressed) folder (in the order shown on checklist; see Page 7). File name must include mentee’s full name, state and year. For example, Jane Doe’s mentee application should be saved as Jane Doe_Texas_2015.pdf.

Send file to Natasha McCoy at . Information should be sent no later than Friday, November 21, 2014 by 5:00 PM EST.

ATTACHMENT A

The following is an example of a Memorandum of Agreement to be signed by the selected mentee and mentee’s supervisor.

SAMPLE MEMORANDUM OF AGREEMENT FOR

NATIONAL MENTORSHIP PROGRAM IN APPLIED CHRONIC DISEASE EPIDEMIOLOGY

The National Association of Chronic Disease Directors (NACDD) and the (Name of State) State/Local Department of Health (hereafter referred to as “the State”) agree to support the chronic disease epidemiologist (Mentee Name) to participate in the National Mentorship Program in Applied Chronic Disease Epidemiology (hereafter referred to as “the mentoring program”) and support his/her selected project at the (Name of State) State/Local Department of Health for up to twelve (12) months beginning December 2014.

I. RESPONSIBILITIES OF MR/MS (Mentee’s Name)

A.Responsibilities to the State

Mr/Ms (Mentee’s name) will assist the (State/Local Health Department) by using health data, especially population-based data, to perform the essential functions of a chronic disease epidemiologist.

Activities should emphasize the following:

Surveillance

  • Collect, analyze and interpret science-based data to assess the burden of chronic disease, provide information on the distribution and risk factors for chronic diseases necessary for public health program planning and implementation, and assist in evaluating the success of public health programs.

Communication

  • Disseminate the results of epidemiologic efforts to support science-based decisions about health issues by policy-makers, programs leaders and the general public.

Consultation

  • Provide decision-makers with information necessary for planning, implementing and evaluating public health programs and policies, and for establishing goals and priorities related to chronic disease.

Evaluation

  • Design, implement, and coordinate scientifically-sound evaluations of the outcomes of health services, health promotion and disease prevention programs, assessing effectiveness, accessibility and quality.
  • Assist program managers and decision-makers by providing information on using evaluation results to increase the effectiveness of existing programs and to design new programs that address identified needs.
  • Perform evaluation research activities including the analysis and interpretation of data about program impacts, using both qualitative and quantitative methods.

B.Responsibilities to NACDD Mentoring program

1.Mr./Ms. (Name of Mentee) with agreement from her/his supervisor and his/her assigned mentor’s consultation decide on a project topic, prepare a brief summary of major project, participate in the monthly conference call with other mentees, and complete his/her project within nine (9) months. The final project report along with a two page summary of the mentee experience should be sent to his/her immediate supervisor, mentor and NACDD.

2.Mr/Ms (Name of mentee) should make his/her best attempt to attend the CSTE annual conference and NACDD Evaluation Workshop, if there were support available.

II. RESPONSIBILITIES OF THE EMPLOYER

A.Provision of state/local support: The mentee’s immediate supervisor agrees to support the mentee’s project and allows her/him to allocate up to 25% of his/her time on the jointly agreed project.

B. Assurance that Mr/Ms (Name of mentee) will be permitted by the Agency to attend the following meetings:

  1. CSTE Annual Conference
  2. NACDD Evaluation Workshop
  3. Monthly conference calls

National Mentorship Program in Applied Chronic Disease Epidemiology (Mentorship Program)

2014-2015Checklist

Before submitting your complete package, please make sure you have included the following:

___ (1) an application (first two pages of this document,

___ (2) a description of the competencies and skills to be developed,

___ (3) a brief description of the anticipated project,

___ (4) an overview of the agency’s capacity for chronic disease epidemiology,

___ (5) a letter of supportfrom the Deputy or State/Local Health Director,

___ (6) a letter of support from the Chronic Disease Program Director agreeing to the terms of the mentorship arrangement,

___ (7) a letter of support from your immediate supervisor if this person is not the same as the Chronic Disease Director

___ (8) and this checklist.

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