<table style="width:100%;">
<colgroup>
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 33%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="20">MENTOR INFORMATION FORM</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="2">Name:</td>
<td colspan="18">     </td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="2">Code:</td>
<td colspan="3">     </td>
<td colspan="2">Phone:</td>
<td colspan="3">     </td>
<td>Email:</td>
<td colspan="2"></td>
<td colspan="6">     </td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="4">Job Title/Grade:</td>
<td colspan="15">     </td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="20">EXPERIENCE:</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="20"><p>Please provide a brief career profile (summary of
work experience, educational background, hobbies/special interest,
etc.): (Please attached additional sheet if needed)</p>
<p>     </p></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="6">Number of years at GSFC:</td>
<td colspan="3">     </td>
<td colspan="6">Number of years in current position</td>
<td colspan="5">     </td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="20"><p>List other professional work or fields you’ve had
exposure to: (e.g., you are currently a resources manager, but formerly
an engineer)</p>
<p>     </p>
<p>DESCRIBE THE TYPE OF DEVELOPMENT EXPERTISE YOU CAN PROVIDE:</p>
<p>Note any that apply:</p>
<p>     </p></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="17"><p>I have a good understanding of career paths in the
following fields:</p>
<p>     </p></td>
<td colspan="7"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="16"></td>
<td></td>
<td colspan="7"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="16"></td>
<td colspan="6"></td>
<td colspan="4"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>I have</td>
<td colspan="2">     </td>
<td colspan="19">years of supervisory experience.</td>
<td colspan="4"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="23"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="25">I have technical expertise in the following
area(s):</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="18">     </td>
<td colspan="3"></td>
<td colspan="7"></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="18"></td>
<td colspan="3"></td>
<td colspan="7"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="18"></td>
<td colspan="5"></td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="30">I have been involved in the following community
outreach activities:</td>
</tr>
<tr class="odd">
<td colspan="20">     </td>
<td colspan="10"></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 11%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 13%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 13%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11">Name/Code:</td>
<td colspan="6">     </td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="6"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
<td colspan="6"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="17">WHAT ADDITIONAL SKILLS DO YOU HAVE TO OFFER AS A
MENTOR? (CHECK <u>ANY</u> OR <u>ALL</u> THAT APPLY)</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="17"><p> An understanding of how NASA GSFC works: culture,
organizational knowledge</p>
<p> Excellent communication skills</p>
<p> Provide a good sounding board to explore career options</p>
<p> Understand the shortcuts for overcoming obstacles</p>
<p> Can offer a different perspective</p>
<p> Can share self motivation techniques</p>
<p> Like to help others build confidence and take on new challenges</p>
<p> Other     </p></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="6">HAVE YOU EVER HAD A MENTOR?</td>
<td colspan="11"> Yes No</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="7">HAVE YOU EVER BEEN A MENTOR?</td>
<td colspan="10"> Yes No</td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="17">WHY ARE YOU INTERESTED IN BEING A MENTOR?</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="17">     </td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="5">DO YOU HAVE THE TIME?</td>
<td colspan="13"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="18">Realistically, how much time can you invest in the
mentoring partnership?</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="18"> 1 hour per week 2-3 hours per week 4 or more hours per
week</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="17"><p>Can you commit to attending the training and
informal sessions that are part of this</p>
<p>program?</p></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="17">(About 1/2 day per month) Yes No Not sure</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="17"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="17">Do you require any special accommodations such as a
sign language or oral interpreter,</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="15">training materials in an alternate format, etc.? Yes
No</td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td>Explain:</td>
<td></td>
<td colspan="16">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="16"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="18">I have read the Mentoring Program announcement and
understand the expectations and responsibilities of a Mentor in the
Program, including the need to schedule meetings with my protégé during
official duty hours and attend developmental training sessions.</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="3">Signature/Date:</td>
<td colspan="9"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="18">I understand that ___________ has applied to
participate in the Goddard Mentoring Program. I agree to work with
him/her on a schedule that balances his/her job responsibilities and
time to participate in the program during official duty hours.</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="18"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4">Supervisor’s Signature/Date:</td>
<td colspan="4"></td>
<td></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="16"><p>RETURN TO NICHOLE RICHMOND, CODE 114, NO LATER THAN
SEPTEMBER 13, 2000</p>
<p>Faxed copies acceptable – send to 6-1679 Voice/TTY 6-1972</p>
<p>Privacy Act Statement</p>
<p><u>AUTHORITY:</u> The Government Employees Training Act of 1958 (USC
Title 5, 4101 to 4118), EO 9397, November 1943 (SSN).</p>
<p><u>PURPOSE AND USE:</u> The information requested regarding your
interest and preferences in a mentor/mentee relationship is to assist
the Office of Human Resources in matching volunteer mentors and protégés
to assure a successful relationship. The submission of privacy act
information is voluntary.</p></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

[DISCLOSURE:]{.underline} Personal information provided on this form is
given on a voluntary basis. Failure to provide this information will not
result in ineligibility for the mentoring program, however it may result
in an unsuccessful match.