Resident Grant Mentor Form Catch Project printable pdf download

Resident Grant Mentor Form Catch Project

Resident Grant Mentor Form

Please provide the following information:

Applicant’s name

: ___________________________________________________________________

Institution name:___________________ ______________________________________

Institution location (city/state): ______________________________________________

Proposed project title: ____________________________________________________

Proposed project objectives:

1. __________________________________________________________________

2. __________________________________________________________________

3. __________________________________________________________________

Mentor’s name:

_________________________________________________________

Mentor’s institution (if applicable):___________________________________________

Mentor’s address: ________________________________________________________

________________________________________________________

Mentor’s phone number: ___________________________________________________

Mentor’s email address: ___________________________________________________

Mentor’s Statement:

Please describe your plans for interacting with the applicant during the project; eg, frequency of meetings and

specific assistance you will provide.

Please be aware Institutional Review Board (IRB) approval may be required

by your institution for the CATCH grant.

__________________________________________________________________________________________________

__________________

your agreement to serve as a mentor for this applicant:

Please state

I have met with this applicant and we have discussed the project described in this application. I understand that this project should be

completed approximately 6 months after funding is received. I have reviewed the “Role of the Mentor” below. This statement

indicates my agreement to guide and assist the applicant with the timely completion of this project as outlined in the project

description above.

Name and Title: ____________________________________________________

Signature: ________________________________________________________

Date: _____________________________________________________________

Resident Grant Mentor Form Catch Project