Full Name: Katherine J
NEW DIRECTOR MENTOR PROGRAM
APPLICATION
The purpose of this application is to learn about your state program and to have a better understanding of the issues you currently face in your new position as aTitle V MCH/CSHCN director. Using the following information, AMCHP will pair you with a mentor Title V MCH/CSHCN director that has similar program responsibilities, state structure, and has experienced similar challenges. Please email or fax your application to Librada Estrada at or fax #: 202-775-0061.
Name, Address & Demographic Information
Full Name:
Degree(s) Completed:
Position Title:
Do you oversee: MCH programs onlyCSHCN programs only Both
Organization:
Address:
City, State, Zip:
Phone:
Fax:
Email:
*Sex:
Female / Male*Ethnicity:
Hispanic or Latino / Not Hispanic or Latino*Race (check all that apply):
American Indian or Alaskan Native / Native Hawaiian/ Pacific IslanderAsian / White
Black or African American / Some Other Race
*The information will only be used for aggregate purposes.
Years of Experience
A. How long have you served as the Title V, MCH and/or CSHCN director for your state (please select one)?
6 months or less7 months – 12 months
13 months – 18 months
19 months – 24 months
25 months – 36 months
More than 36 months (you are not eligible to participate in this program)
B. Have you previously been a state Title V, MCH and/or CSHCN director in another state?
Yes / If yes, how long did you serve and where? ______No
Program Areas
C. Which MCH/CSHCN or related programs/activities are within your administration or management responsibilities?
Check () all that apply even if only part of the program/activity is under your management.
Birth Defects/Genetics / MCH Epidemiology
Breast & Cervical Cancer / MCH Surveillance (PRAMS, YRBS, Birth Defects Surveillance, etc.)
Childhood Injury Prevention/EMSC / Medical Home Program
Chronic Disease / Newborn Blood Spot Screening
Data Analysis/Epidemiology / Newborn Hearing Screening
Direct Care CSHCN Program / Oral Health
Domestic Violence (including rape crisis) / Program for Care Coordination and Financial Assistance
Early Childhood Comprehensive System / Reproductive Health (separate of Family Planning; e.g. STI and STD education, screening, treatment, etc.)
Early Intervention—Part C IDEA / Ryan White
Family Planning/Title X / Supplemental Security Income (SSI) Disabled Children’s Program
Immunization / Transition Program
Home Care Waiver Program / WIC (Women’s Infant and Children Nutrition Program)
Infant Mortality Reduction (including Healthy Start) / Women’s Health
Infant/Child Death Review / Other, specify:
D. Indicate from the following list the structure of your program.
Level of Service / Percentage / CommentsInfrastructure building
Population-based
Enabling services
Direct health care
E. What are your administrative responsibilities for these programs?
Contract managementProgram/Policy development
Direct Services management
MCH Block Grant Administration
Other:
F. What are some of the major issues directly impacting your state’s MCH/CSHCN program? (e.g. balancing direct service delivery and other core functions of public health, integrating MCH/CYSCHN services into the larger agency services, agency reorganization, program design to target populations, budget challenges)
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3.
G. Have you reviewed AMCHP’s publication Leading State MCH Programs: A Guide for Senior Managers?
YesNo, but I have a copy of the resource.
No, because I do not have a copy and would like to have a copy emailed to me.
H. Is there a particular state MCH/CSHCN program with which you would like to be paired?
Yes (please complete question I)No (go to question J)
I.If yes, please list the state(s) and your reason for requesting the state(s).
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2.
3.
NOTE:Your responses for the following items (J—M will be shared with the individual that is selected as a mentor).
J. What are some areas and issues you would like to address during a site visit?
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2.
3.
- What would you like to gain by participating in this program?
- What expectations would you have of a mentor?
- Please insert (or send) your current BIO information below (one-page please).
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