Appendix C

Mentor Consent Form

The role of the Mentor is to serve as an expert in the field chosen by the student. By signing this form, the
mentor agrees to: allocate time (a minimum of ten hours) to work with the student; provide insight into the
training, expectations, and demands of the field; ensure that the student is actively involved during shadowing
and not simply observing. If desired, the mentor may provide suggestions, advice, and support regarding the
development of a tangible product that connects to the real-world requirements of the career.

Student Name​ __________________________________________________________________

Bethany Costello

Project Topic ___________________________________________________________________

Design and implementation of a public health information campaign

Mentor Name​ ___________________________________________________________________

Elizabeth Jackson

Place of Employment _____________________________________________________________

Mailman School of Public Health, Columbia University

Work Address ____________________________________________________________________

60 Haven Avenue, Suite B-2, New York, NY 10032

Preferred Email __________________________________________________________________

ej2217@columbia.edu

Preferred Phone _________________________

646-660-5228

Occupation / Title / Expertise Related to Topic Epidemiologist/Adjunct

___________________________________________
Associate Research Scientist/
Qualitative and quantitative research methods, health systems research, maternal, child,
________________________________________________________________________________
adolescent health

Years of experience in topic area ____________________

20

For the protection of myself and the student, I agree that we will not meet alone. I agree to uphold the
roles/duties of the project mentor to the best of my ability. I also confirm that I am not related to the student.

Mentor Signature​ ________________________________________________ Date ______________

October 1, 2018

Parent Signature​ _________________________________________________ Date ______________

Student Signature​ ________________________________________________ Date ______________