Mentee Feedback Form Date*The following questionnaire is to be completed by the mentéé at least every 8 weeks and forwarded to the co-ordinator. This questionnaire may only be completed once the mentor and mentéé have had an in-depth discussion as to the mentéé’s progress, albeit not. The tangent planes referred to in this questionnaire are those dimensions of behaviour that impact significantly on a mentors effectiveness. Each tangent plane is measured on a scale of 1 to 5. Please use the following guideline when awarding a mark: 5 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL In addition to the rating, critical incidents relating to both positive performance as well as grey areas relating to that specific dimension needs to be jotted down. If the mentéé needs to make any other comments, these may be jotted down in the General Comments column. Mentéés are required to submit a feedback appraisal form to the Katuka Programme Director in April, July and October of each year.Mentee Name*FirstLastMentor Name*FirstLast1. My mentor is approachable and willing to assist *Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL2. My mentor is a source of motivation for me. *Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL3. My mentor contributes to my growth in existing and/or new skills/knowledge.*Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL4. My mentor gives me enough space to learn from my mistakes.*Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL5. My mentor contacts me regularly and gives regular structured feedback. *Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL6. My mentor and I jointly contracted SMART objectives.*Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL7. My mentor is actively involved in my development programme.*Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL8. My mentor is at all times willing to listen to my challenges and render assistance. *Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL9. I implicitly trust my mentor’s integrity regarding the confidentiality with regard to my progress.*Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMAL10. My overall rating of my mentor.*Give example/describe the incident brieflyYour rating*123455 = ALWAYS – without fail / EXCELLENT 4 = MOST OF THE TIME / GOOD 3 = OFTEN / AVERAGE 2 = SELDOM / POOR 1 = NEVER / DISMALGeneral comments and additional notes.*SendThis field should be left blank
