Questionnaire for Profiles of Peer Mentor Programs

Institution/Organization, Contact Information and brief institution description

1. Name of Institution/Organization
2. Please provide contact information (name, address, phone, email & website)

Organizational Structure

3. How is your Peer Program aligned with your organization strategies and/or goals?
4. Who were the initial members of your Peer Mentoring Program planning team?
5. Tell us your Peer Mentor Program reporting structure?

Staffing

6. Tell us about your Peer Program coordination and dedicated staffing (including supervision and ongoing support for the mentor)?
7. Share with us some specifics about your Peer Program dedicated staff--
   1. Specific educational degree
   2. Salary range
   3. Full or part time

Finances and Operating Budget

8. How do you financially support your Peer Program (i.e. Operating Budget)?

Models and Locations of Peer Mentors

9. When did you start providing Peer Mentor Programs?
10. Tell us about the Peer Models you provide:
    1. One to One
    2. Group Support
    3. Hybrid
11. What departments/areas do you provide Peer Programs?
12. Which clinical setting(s) is your Peer Mentor Programs offered:
    1. Hospital (inpatient)
       1. Unit specific
       2. Diagnosis Specific
       3. ICU/Trauma
    2. Specialty Clinic
    3. Outpatient/Ambulatory

Size of Program

13. How many active Peer Mentors are in your program?

Recruitment, Training, Management and Support

14. Tell us about your Peer recruitment, training and support.
    1. How do you recruit your peers?
    2. How many hours of training do you require?
    3. Do you provide additional ongoing peer education?
    4. Tell us about who matches your peers, and a little bit about your matching protocol (process by which peers are matched with mentees)?
    5. How is your Peer Program aligned with psychosocial support?
    6. How are your peers recognized and celebrated?
15. How do you evaluate your Peer Program.
    Please include how your PROGRAM is evaluated and how your MATCHES are evaluated?

Evaluation and Sustainability

16. Share with us your plans for sustainability or growth?

Research

17. Do you have any published research?