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Checkup Form

Date (mm/dd/yy)

Mentor Information

First Name
Last Name

Mentee Information

First Name
Last Name

Checkup Information

Number of Contacts (Give a Number)

Average Length of Contact (Choose any one) Less than 15 minutes
15-30 minutes
30-45 minutes
45 minutes to 1 hour
Over 1 hour

Primary Method of Contact (Choose any one) Personal meeting(s)

What topics did you cover in your discussions? Career (Current Job, Previous Work Experience, Career Interest/Goals/Plans or Career Assistance at UTA)

Education (Experience(s), plans, or resources at UTA)

Mentor's Background (Career experiences, education experiences, or personal experiences)

Mentee's Background (Reassurance/Support, Student Organizations, Campus Events, Arlington/Metroplex)

Mentoring Relationship (Contact, meetings expectations or needs)


What services/resources/information have you provided for your mentee over the past month?
Briefly discuss how you feel the mentoring relationship is going, noting any activities you and your mentee have participated in together?

Updated 1/09 - You may be entitled to know what information The University of Texas at Arlington (UT Arlington) collects concerning you. You may review and have UT Arlington correct this information according to procedures set forth in UTS 139. The law is found in sections 552.021, 552.023 and 559.004 of the Texas Government Code.