The Iowa Mentoring Partnership (IMP) is committed to supporting and expanding quality mentoring services bypromoting the use of the National Mentoring Partnership’s Elements of Effective Practice for Mentoring™. Thecertification process is intended to help mentoring organizations determinewhether their program is meetingeach element and implementing quality services that are most likely to yield positive results for mentees,mentors, parents and other participants. The IMP does not assume responsibility or liability for the actions orinactions of individualmentoring programs.

Programs that do not meet the Elements of Effective Practice will be offered technical assistance and otherresources to help meet the elements in the future.

If you have any questions, please contact the IMP via e‐mail (mentor@iowa.gov) or by phone (800.308.5987).We also encourage you to visit the IMP’s website (www.iowamentoring.org) to learn more about programcertification and the Elements of Effective Practice.

Certification and Recertification Application

CONTACT INFORMATION

Mentoring Program Name:

Parent Organization, if applicable:

Address:

City: State: Zip:

Phone: Fax Number:

Website:

Executive Director: Phone:

Email address:

Mentoring Program Contact Person Phone:

Email address:

Year Mentoring Program Founded:

   

   

   

   

                 

                       

                         

               

                   

           

           

                           

                 

GENERAL INFORMATION

1. How many mentoring relationships are currently active in the program?

2. How many new matches did the program make in the last calendar year?

3. How many youth are currently accepted to your program and ready to be matched?

4. How many mentors are currently ready to be matched?

Yes No5. Do matches have the option to continue from year to year?

6. What county (ies) does the program serve?

6a. Additional comments on your service area:

7. What is the primary newspaper outlet in your community? (used for distribution of statewide IMPpress releases):

8. Please list social media platforms used and social media handles.

PROGRAM GOALS

For mentees:

For mentors:

               

                 

                

                 

             

                           

    

  

 

   

    

                               

                                                            

              

          

   

                 

   

                   

 

 

PROGRAM DESIGN AND PLANNING (MORE INFORMATION IS ONLINE)

9. What youth population does the program serve?a. Mentee age range:b. Mentee grade range:

c. Gender: Male Femaled. Racial Demographics (check all that apply)

o American Indian / Alaskan Nativeo Asiano Black / African Americano Hispanic / Latino(a)o Native Hawaiian or Othero Pacific Islandero White / NonHispanico MultiRacialo Other

di. Target populations, for example foster care, school attended:

10. Identify the types of individuals that will be recruited as mentors (check all that apply)o Faith‐basedo College studentso High School studentso Corporate employeeso Community at‐largeo Senior Citizenso Other:

Please specify

Minimum age:

11. What is the mentoring model used? (check all that apply)o E‐mentoring (one to one via secure online platform)o One on One (one mentor to one mentee)o Peer to Peer (older youth mentoring younger youth)o Group ( one mentor with more than one mentee)o Team ( more than one adult with more than one mentee)

12. Mentoring takes place (check all that apply)o During school hourso At school, after school hourso In the communityo Other

Please explain

13. Is your program: A stand alone organization (501c3) Part of an existing organization Other

Please specify

14. Define the nature of the mentoring sessions (check all that apply)o Socialo Academico Career Awarenesso STEMo Other:

Please specify

                                      

  

 

                       

   

     

   

     

 

     

          

     

                                     

15. What is the minimum time commitment that your program requires for mentoring relationships?(respond to each structure as applicable to your program)

REQUIREMENTS

Minimum match commitment

PROGRAMMODEL

SCHOOL/SITE BASED

Other: Other: Other:

COMMUNITY BASED

Other: Other: Other:

E‐MENTORING

Other: Other: Other:

OTHER (PEER, GROUP,ETC.). PLEASE SPECIFY:

Other: Other: Other:

Number of meetings per month Length of each meeting

15a. If needed, please provide further description of the minimum time commitments requiredfor mentoring relationships in the program.

                                  

            

                      

          

           

   

             

                          

   

               

   

                                                  

      

      

  

   

    

PROGRAMMANAGEMENT (MORE INFORMATION IS ONLINE)

Management Team

16. What is the mission statement of your program?

17. Does your mentoring program have a team tasked with oversight? Yes, Advisory Committee Yes, Board of Directors Yes, Other

Please specify No

18. How often does the advisory board/board of directors meet? Monthly Quarterly Annually Other

Please specify

19. Does your program have a system in place for the following? (check all that apply)o Budgeting for operationso Managing program financeso Internal controls/audit requirementso Developing policies and procedureso Reviewing policies/procedures/operationso Managing personnel recordso Tracking of program activityo Mentor/mentee matching processo Documenting mentoring matcheso Written risk management policyo Program evaluationo Marketingo Mentor recruitmento Mentor recognitiono Mentor/mentee closure/exit interview

Risk Management

20. Do you a have fully approved risk management plan on file with the IMP, which includes the followingstandards ?

Yes Noa. Written risk management plan:Yes Nob. Appropriate/Inappropriate touch training for mentees:

c. Reporting inappropriate contact training for mentees and parents/caretakers: Yes No

Yes Nod. Appropriate/inappropriate contract training for mentors provided:Yes Noe. Reporting inappropriate contact for mentors:

Yes Nof. Safe meeting places:

                            

          

   

  

 

          

   

Financial Plan21. What funding sources do you use to sustain your budget? (check all that apply)

o Corporate/Businesso Iowa Department of Public Healtho Other State funds

Please specify

o Federal Grants/Fundso State/National Foundations/Grantso Local Foundations/Grantso Fundraisingo United Wayo City Fundso County Fundso In‐kind donations (volunteers, materials, etc.)o Other

Please specify

                 

                

                                          

                       

 

           

                

   

                  

              

   

 

                                

                   

                             

                 

                   

            

               

     

   

OPERATIONAL STANDARDS FOR MENTORING PROGRAMS (MORE INFORMATION IS ONLINE)

Recruitment22. Which of the following does your recruitment policy incorporate? (check all that apply) Realistically portray the benefits, practices, and challenges of mentoring in the program Recruit youth whose needs best match the services offered by the program

Screening23. What requirements do you have for your mentors? (check all that apply)

o Written applicationo Interviewo Reference checko Home visito National Sex Offender Public Registry Checko State of Iowa DCI Background Checko States checked other than Iowa:

Please list

o FBI National Fingerprint Background Checko Driving recordo Child Abuse Registry Indexo Iowa Courts Onlineo Skills requiredo Attend trainingo Age range / Minimum age:

Please specify

o OtherPlease specify

Training

24. How many hours should a volunteer expect to spend in in‐person pre‐match activities (volunteerorientation, training, screening, interview, etc.)? Less than 2 hours 2 ‐ 4hours 4 ‐ 6hours 6 ‐ 8hours More than8hours

25. Are the following components covered in the mentor training offered by your program? (check all thatapply)

o Program requirements (e.g., match length, meeting frequency and duration, matchtermination)

o Mentor’s goals and expectations for the mentee, parent/caretaker, and the mentoringrelationship

o Mentor’s obligations and appropriate roleso Relationship development and maintenanceo Ethical and safety issueso Effective Closureo Sources of assistance to support mentorso Risk management for mentorso Other

Please specify

                  

                                                

     

                            

      

        

   

               

   

   

                        

                       

                                           

Matching26. Which of the following are components of your matching policy? (check all that apply) Considering program goals as well as the characteristics of thementor andmentee whenmakingmatches Arranging and documenting an initial meeting between thementor andmentee

Monitoring and Support

27. Does the program provide ongoing support and supervision for the following? (check all that apply)o Training Frequency:o Group activities Frequency:o Individual meetings Frequency:o Written/phone correspondence Frequency:o Assistance with first meetingo Other

Please specify

28. Case management protocol: Program staff contact/support mentor and mentees Weekly Monthly Every threemonths Other:

Please explain

Closure29. Which of the following does your Closure policy include? (check all that apply)

o Procedure to manage anticipated closures, including a system for a mentor or menteerematch

o Procedure to manage unanticipated match closures, including a system for a mentor ormentee rematch

o Conduct and document an exit interview with the mentor and mentee

           

                                

                          

             

                       

 

 

   

                                                                                              

                        

                          

   

                                                                                                                                                              

                             

                                   

                                  

   

 

      

PROGRAM EVALUATION (MORE INFORMATION IS ONLINE)

Yes No30. Do you have a plan to measure program process?If yes, does it include: (check all that apply)

o Indicators of program implementation and volunteer fidelity, such as training hours,meeting frequency and relationship duration

o A system for collecting and managing specified data

31. Does the program conduct evaluations with the following groups? (check all that apply)o Menteeo Mentoro Program staffo Parento Teacher/School staffo Other

Please specify

32. What outcomes does your program use to determine the success of a relationship? (check all that apply)o Will the match continue meeting the next year?o Did the mentees enjoy their involvement?o Did the mentors enjoy their involvement?o Did the mentors feel that mentoring had positive impact on youth?o Did the parents/guardians notice improvement in their children?o Improvement in school attendance (absences, tardiness, etc.)o Improvement in academic performance (standardized tests, grades, etc.)o Decrease in disciplinary referralso Mentee identifies more trust toward adultso Mentee displays improved attitude about their futureo Other outcomes

Please specify

Quarterly ReportsAs a condition of certification, each program is asked to complete four, brief reports throughout the year.Only programs that are in good standing, which means those whose recertification applications andquarterly reports are consistently submitted on time, will be eligible to receive the benefits of programcertification. Programs that miss more than two quarterly reports per year may not be grantedrecertification with the IMP. Each quarterly report allows the IMP to collect local mentoring data that helpsto illustrate mentoring trends, educate state legislators and “make the case” for mentoring in Iowa.

CertificationBy submitting this document, I hereby certify that the information contained herein is true and correct. Iunderstand that the Iowa Mentoring Partnership may request supporting documentation to confirm thatthe information submitted is accurate.

Typed Name:

Title:

Date:required format: dd/mm/yyyy