Form DCF-3002 "Annual Report - One on One Mentoring Program" - Connecticut

What Is Form DCF-3002?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2016;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-3002 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-3002 "Annual Report - One on One Mentoring Program" - Connecticut

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Department of Children and Families
ONE ON ONE MENTORING PROGRAM – ANNUAL REPORT
DCF-3002
8/16 (Rev.)
Page 1 of 4
Name of Private Agency:
Name of Contact Person:
Phone #:
Year Reporting On:
Today’s Date:
For the year in which your agency is reporting, please provide the following information in narrative form. You may include tables or attach additional
pages if needed to describe the various components of Mentoring Program services offered:
1.
Please describe your Mentoring Program structure, including staff involved with program and their duties:
2.
Please list your Mentoring Program recruitment efforts: include list of events which the agency participated in and any initiatives or outreach efforts made to
recruit mentors. Specify any special targeted recruitment (race, ethnicity, gender, etc.)
3.
Please list trainings provided to mentors and mentees during the year:
3A. Please include the number of who attended your
Gender:
Ethnicity:
training efforts::
Male:
Female:
Hispanic Origin:
Not of Hispanic Origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander: White:
Other:
Sorted by Race:
Department of Children and Families
ONE ON ONE MENTORING PROGRAM – ANNUAL REPORT
DCF-3002
8/16 (Rev.)
Page 1 of 4
Name of Private Agency:
Name of Contact Person:
Phone #:
Year Reporting On:
Today’s Date:
For the year in which your agency is reporting, please provide the following information in narrative form. You may include tables or attach additional
pages if needed to describe the various components of Mentoring Program services offered:
1.
Please describe your Mentoring Program structure, including staff involved with program and their duties:
2.
Please list your Mentoring Program recruitment efforts: include list of events which the agency participated in and any initiatives or outreach efforts made to
recruit mentors. Specify any special targeted recruitment (race, ethnicity, gender, etc.)
3.
Please list trainings provided to mentors and mentees during the year:
3A. Please include the number of who attended your
Gender:
Ethnicity:
training efforts::
Male:
Female:
Hispanic Origin:
Not of Hispanic Origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander: White:
Other:
Sorted by Race:
Page 2 of 4
4.
Supervision provided to mentors and mentees during the year: Please specify number of mentors and mentees for which you provided supervision. Describe
the nature and purpose of the supervision and how mentors and mentees benefited or not from supervision.
5.
List and describe all group activities provided during the year: Include the date, topics, and numbers of attendees. Distinguish between number of mentors
and mentees and sort by gender, race and ethnicity. Indicate if your event included people who are not matched:
6.
Agency wide events provided to mentors and mentees: Describe the event, number of matched mentors and mentees who attended. Number of non-
matched mentors and non-matched mentees. Give a narrative account of the highlights of this event.
Page 3 of 4
7.
Described any obstacles encountered that had a direct impact on your ability to successfully provide this service:
8
Please provide "client satisfaction surveys" data: Include total surveys received, how you gathered information, sort by race and ethnicity. Please provide
referral source satisfaction surveys data. Indicate where the completed surveys are
stored.
9.
Highlight any program or individual mentor/mentee success stories (include unique volunteers and interns) You are welcome to include any digital photos as
an attachment.
Page 4 of 4
10. Total number of ACTIVE matches:
Gender
Ethnicity:
Male:
Female:
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
11. Total number of ALUMNI matches:
Gender
Ethnicity:
Male:
Female:
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
12. Total number of MENTORS RECRUITED:
Gender
Ethnicity:
Male:
Female:
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
13. Total number of MENTORS SCREENED:
Gender
Ethnicity:
Male:
Female:
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
14. Total number of MENTEES REFERRED:
Gender
Ethnicity:
Male:
Female:
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
15. Total number of MENTEES MATCHED:
Gender
Ethnicity:
Male:
Female:
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
16. Total number of MENTEES on waiting list:
Gender
Ethnicity:
Male
Female
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
17. Total number of MENTEES waiting to be matched
Gender
Ethnicity:
at the end of the year:
Male:
Female:
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
18. Total number of MENTOR/MENTEES who had a
Gender
Ethnicity:
minimum of 3 face to face contacts per month:
Male:
Female:
Of Hispanic Origin:
Not of Hispanic origin:
American Indian/Alaskan Native:
Asian:
Asian Indian:
Black:
Pacific Islander:
White:
Other:
Sorted by Race:
19. Average length of time from referral to match:
Additional Comments:
Page of 4