Association of State Public Health Nutritionists
Health Equity Internship Program
Preceptor and Site Application Form
I. Preceptor Information
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Last Name First Name Middle Name
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Work Address
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City State Zip Code
Work Number ______Other Telephone Number(s) ______
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Work Mailing Address (if different from above)
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City State Zip Code
Email Address: ______
Optional Information
The following is requested solely to provide information regarding the demographics of applicants. It is not needed for the review and selection process for placement sites. While it will be helpful to the program’s sponsors, you are not required to complete it.
Ethnic Origin:____African American/Black ____Black/Non-African American ____American Native or Alaskan Native
_____Asian____Hispanic (specify):______
_____Pacific Islander_____White/Caucasian_____Other
II. Education/Professional Information
Highest Degree
Degree:______Field:______
Year:______University:______
2nd Highest Degree
Degree:______Field:______
Year:______University:______
3rd Highest Degree
Degree:______Field:______
Year:______University:______
List Professional Memberships:
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III. Work History
Current Employer:______
Department /Office:______
Current Position:______
Immediate Supervisor and Title:______
Email address:______
Employed Since:______
Month Year
Most Recent Former Employer:______
Department /Office:______
Title of Position(s) Held:______
EmploymentDates:______
Month Year
Have you previously participated as a preceptor an internship or fellowship program? ___ Yes ___No
If yes, list all programs: ______
Computer Literacy (Please check all applications in which you feel you are proficient):
______
___Desktop Publishing (any programs – specify)______
___Statistical Analysis (any programs – specify)______
___Other (specify):______
Please specify the level of fluency in oral and written Language Skills other than English.
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IV. Internship Content Area
Please check below the content area an assigned intern would gain experience from during the internship:
_____Health Equity
(e.g. health disparities, social determinants of health, cultural competency)
_____Health Promotion Science
(e.g. behavioral theory, human behavior, domains)
_____Health Promotion Intervention Adaption/Replication
(e.g. recruiting, participation, cultural competency, delivery of health education messages, curriculum development)
_____Policy Development/Implementation
(e.g. individual and community assessment, planning, service provision, advocacy)
_____Policy Evaluation
(e.g. types of data sources, collection issues, outcome monitoring)
_____Population Based Needs Assessment
(e.g. qualitative and quantitative research methods, community input, resource inventories)
_____Social Marketing and Behavioral Change Communication
(e.g. techniques, tools, health communication)
_____Intervention Effectiveness
(e.g. applying behavioral/social science theory, assessing effectiveness)
_____ Other Policy related area
Please check one to three health promotion and chronic disease prevention areas of interest for the intern’s experience:
____ CVD/Stroke____ Cancer Prevention/Intervention____Minority Health____School Health
____ Diabetes____ HIV/AIDS Prevention/Intervention____ Tobacco ____ Injury Prevention
____ Asthma____ Physical Activity ____ Men’s Health____ Nutrition
____Arthritis____ Osteoporosis ____ Women’s Health____Reproductive Health
____Aging____ Genomics____Other (specify)____Youth/Adolescent Health
____Infectious Disease____ Environmental Health____Maternal/Child Health
V. Description of Major Internship Activities
Please briefly describe proposed activities for anintern. Make sure to include the education level (bachelor, master or doctorate), desired discipline the intern should have and technical skills and talents sought in anintern. Keep in mind the internship placements are 12 weeks. The intern is required to produce a scholarly report and abstract worthy to be considered for a professional conference at the conclusion of the internship.
Please suggest other methods for promoting the Health Equity Internship Program within your agency.
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Please submit the completed application via e-mail to:
Manager of Internship Program
ASPHN Health Equity InternshipProgram
3401 12th Street, NE, #29046
Washington, DC 20017
Phone: (202) 903-6792
E-mail: