MPH Program

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Field Placement Forms

Information and links are provided below for the forms that must be filled out by:

Form	Available as:		Sample	Submission Deadline
Field Placement Handbook		PDF		Review continuously throughout MPH program
Timeline of Responsibilities		PDF		Begins 4 months before enrollment
Student Responsibility Checklist with Deadlines	Fall 12	Spr 13	Sum 13	Begins 4 months before enrollment
Student Interest Form	E-form	PDF		4 months before enrollment in Field Placement course
Competency Self Assessment	DOC	PDF	PDF	4 months before enrollment
Field Placement Proposal	DOC		PDF	At least 6 weeks before enrollment
Field Placement Log	DOC	PDF	PDF	Monthly during Field Placement
Midpoint Progress Report	DOC	PDF	PDF	Before and again after Midpoint Review
Student Evaluation of Preceptor and Field Placement Experience	E-form	PDF		Within 1 week of conclusion of Field Placement
In Special Circumstances:
Early Field Placement Request	E-form	PDF	PDF	4 months before enrollment
Field Placement Waiver Application	E-form	PDF		During first semester of enrollment in MPH Program

Timeline of Responsibilities: 2012-2013 l 2013-2014

Form	Available as:		Sample	Submission Deadline
Letter of Introduction		PDF		Review when student approaches potential Site Preceptor
Site Preceptor Handbook		PDF		Review continuously
Timeline of Responsibilities		PDF		Begins 4 months before student enrollment
Field Placement Site Application	DOC	PDF		2 month before student enrollment
Example of Affiliation Agreement*		PDF		2 months before student enrollment
Field Placement Proposal	DOC		PDF	Student will fill out; Site Preceptor will approve and sign; Student will submit at least 6 weeks before enrollment
Midpoint Progress Report	DOC	PDF	PDF	Student will submit before and again after Midpoint Review; Site Preceptor will approve
Preceptor Evaluation of Student	DOC	PDF		Within 1 week of conclusion of Field Placement

*The Program Coordinator will email you an Affiliation Agreement specific to your organization. This copy is available only as an example.

Timeline of Responsibilities: 2012-2013 l 2013-2014

Form	Available as:		Sample	Submission Deadline
Field Placement Handbook		PDF		Review continuously
Timeline of Responsibilities		PDF		Begins 4 months before student enrollment
Field Placement Proposal	DOC		PDF	Student will fill out; Faculty Advisor will approve and sign. Student will submit at least 6 weeks before enrollment
Midpoint Progress Report	DOC	PDF	PDF	Student will submit before and again after Midpoint Review; Faculty Advisor will approve
Faculty Advisor Evaluation of Student	DOC	PDF		Before the end of the semester

Timeline of Responsibilities: 2012-2013 l 2013-2014