Contact Log
1. Name of Mentor
2. Name of Mentee
3. Did you have contact with the mentee?    Yes      No  
4. Date of activity
5. Total contact time (please indicate in minutes) minutes
     5a. Goal(s) worked on Goal #1       Not applicable  
Goal #2       Not applicable  
Goal #3       Not applicable  

     5b. Was your goal accomplished?

 

 Goal #1:   Yes       No         Not applicable   
Goal #2:   Yes       No         Not applicable   
Goal #3:   Yes       No         Not applicable   
Please tell us about the activity that you spent the most time on:
6. Type of primary activity?    

   6a. If you selected the option "Other" above please specify  

    6b. If you selected the option "Conversation" above please specify the topic discussed  
    6c. Amount of time spent on this activity (in minutes):  minutes
7. Location of the Primary activity (select one)
    7a. If you selected the option "Other" above please specify 

8. Who participated in the Primary activity (select all that apply)?
     A. Mentee  Yes      No  
     B. Mentee Mother/Female caregiver    Yes      No  
     C. Mentee Father/Male caregiver     Yes      No  
     D. Mentee’s siblings     Yes      No  
     E. Other mentee family members   Yes      No  
     G. Other LAMP Family members     Yes      No  
     F. Other (if you pick this please fill out question 8a)  Yes      No  
    8a. If you selected the option Other above please specify
9. How much did you enjoy the Primary activity?
10. What did you enjoy most during the Primary activity?
    10a. If you selected the option Other above please specify
11. Did you do a Second activity? 

 
 Yes     If yes, tell us about your Secondary activity by answering Questions 12 - 16 and then continue on to Question 17.

  No     If no, go to Question 17.
12. Type of Secondary activity:
    12a. If you selected the option "Other" above please specify  
    12b. If you selected the option "Conversation" above please specify the topic discussed
    12c. Amount of time spent on this activity (please indicate in minutes): minutes
13. Location of the Secondary of activity (select one):
     13a. If you selected the option "Other" above please specify
14. Who participated in the Secondary activity (select all that apply)?
     A. Mentee Yes      No  
     B. Mentee Mother/Female caregiver Yes      No  
     C. Mentee Father/Male caregiver    Yes      No  
     D. Mentee’s siblings Yes      No  
     E. Other mentee family members Yes      No  
     G. Other LAMP Family members Yes      No  
     F. Other (if you pick this please fill out question 14a) Yes      No  
    14a. If you selected the option "Other" above please specify 
15. How much did you enjoy the Secondary activity?
16. What did enjoy most during the Secondary activity?
    16a. If you selected the option "Other" above please specifc in the box

17. How was this contact/meeting arranged?

       I arranged this contact with my mentee:

   
      17a. If you selected "By Phone" please indicate the number of calls made to arrange the meeting  
 
18. Rate how easy or difficult it was to make this contact/meeting. 
1
2
3
4
5
Very Easy --------------------------------------------------------------------------------------------------------- Very Hard
 
19. Indicate your level of distress as a mentor in the following areas using the rating scale below.
      A. Problems with the mentee's parents
      B. Mentee struggles with peers
      C. Problems in the relationship with the mentee
      D. Scheduling conflicts
      E. Mentee does not want to attend school
      F. Problems with the mentee's academics
      G. Other (If you indicate a level of distress other than none, please indicate what is causing your distress)
20. To what degree do each of the following keep you from forming an effective relationship (e.g., feeling connected) with your mentee?
      A. Problems with the mentee's parents
      B. Mentee struggles with peers
      C. Problems in the relationship with the mentee
      D. Scheduling conflicts
      E. Mentee does not want to attend school
      F. Problems with the mentee’s academics
      G. Other (Specify)  
21. Please include any additional information you would like to share (optional)