UJIMA PEER MENTOR VISITATION FORM

Each Ujima Peer Mentor is expected to complete this form after visiting with each of his/her assigned Mentee(s) and return it on the due date to the OBSA office.

Due Date Mentor Name

Telephone Number Email

Mentee #1 Name Mentee #1 Phone

Date of Visit

Place of Visit: Type of Visit:

Concern(s) Reported:

Academic/Personal Achievements:

__________________________________________________________

Mentee #2 Name Mentee #2 Phone

Date of Visit

Place of Visit: Type of Visit:

Concern(s) Reported:

Academic/Personal Achievements:

__________________________________________________________

Mentee #3 Name Mentee #3 Phone

Date of Visit

Place of Visit: Type of Visit:

Concern(s) Reported:

Academic/Personal Achievements: