DA‐329 09/04/2014
Kansas Mentors Program: State
Employee Mentoring Request
Employee Name:
myWSU ID #: Work Phone:
Official Job Title:
Department:
Campus Box:
Visit http://community.ksde.org/Default.aspx?tabid=5194 for a list of approved mentoring organizations.
Mentoring Program Name:
Mentoring Program Address:
Mentor Coordinator: Phone:
Proposed Mentoring Schedule:
Day(s) of Week: Hours: From: To:
Start Date: End Date:
I verify that if approved to participate in the State of Kansas Mentoring Leave Program, I will
follow Executive Order 08-10 and Bulletin 08-03 and any subsequent bulletins, regulations,
executive orders, and guidelines covering this program issued by the Governor’s Office, Division
of Personnel Services, and my agency, as well as guidelines issued by the program or school in
which I volunteer.
Employee Signature: Date:
SUPERVISOR REVIEW
Request approved: Request denied:
Comments:
Supervisor Signature: Date:
OHR Signature: Date:
MENTORING COORDINATOR REVIEW
I verify that the above employee has been approved and matched as a mentor with our
organization, and that the employee’s proposed mentoring schedule is valid.
Mentor Coordinator Signature: Date:
Note: The completed form should be kept on file in the Human Resources Office. Campus Box #15.
