This form must be submitted by the student at the conclusion of the practicum. Please complete this form electronically; the text fields will expand as you type. Submit to the Practicum Coordinator, Jessica Howell, via email () or fax 404-413-1489.

Student Name: Click here to enter text. Email address: Click here to enter text.

Panther ID: Click here to enter text.

Concentration or Specialty Track: Click here to enter text.

Practicum Site: Click here to enter text. (office/department/division, if applicable)

Preceptor Name: Click here to enter text. (include credentials – MD, MPH, etc.)

Practicum Dates: from Click here to enter text. through Click here to enter text.

Please evaluate your practicum experience in the section below. This information is only shared with your faculty advisor and practicum coordinator. Indicate your judgment of the following on a scale of 1(LOW) to 10 (HIGH) for each item. Select “Not applicable” (N/A) if the criterion was not addressed during the practicum experience.

Self-Evaluation of Competencies / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / N/A
Understand the strengths and weaknesses of various epidemiologic studydesignsand researchmethods. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Demonstrate expertise in the ethical conduct ofhuman subjectsresearch, including confidentiality and vulnerable populations. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Critically review,synthesize,and evaluate the scientific literature and present appropriate implications for public health practice, public policy, and further research. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Demonstrate proficiency in epidemiological research by: (1) formulating a research questionand/or corresponding hypotheses, (2) developing the study design, (3) participating in data collection, (4) conducting statistical analyses, and (5) interpreting scientific results. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Demonstrate mastery and independence as a researcher by pursuing and completing a specialized area of epidemiologic research. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Effectively present and disseminate findings from epidemiologicresearchto scientific and lay audiences. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Preceptor Evaluation / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / N/A
My preceptor provided orientation (to the site, on policies and procedures, etc.) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My preceptor provided me with opportunities and resources necessary to accomplish the goals in my learning plan. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My preceptor met with me at least weekly to provide supervision and relevant feedback on my project. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My preceptor allowed me to take initiative and be creative. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My preceptor communicated new knowledge and skills in ways I understood. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My preceptor served as an effective professional role model. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
I would recommend this preceptor to other students. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Overall, how would you rate the quality of your relationship with your preceptor? / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐

Please feel free to add comments in the space provided (the text field will expand as you type) or as a separate attachment. Click here to enter text.

Practicum Experience Evaluation / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / N/A
My practicum provided an opportunity to use theory and/or skills learned in the classroom. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My practicum provided me with new skills and contributed to the development of my career interests. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My practicum activities were relevant to my learning objectives. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
I accomplished the goals set forward in my practicum proposal. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My practicum allowed me to contribute to the site in a meaningful way. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My practicum challenged me to perform at my highest level. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
My coursework at GSU adequately prepared me for my practicum. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
The SPH program staff were helpful in assisting me with securing and accomplishing my practicum. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Overall, how would you rate the quality of your practicum experience? / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐

Summary:

Describe new skills you acquired or unanticipated contributions you made to the organization during your practicum experience.

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What types of activities did the PhD program prepare you for in your practicum and what areas could you have used more preparation?

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In what ways can the SPH program staff help improve the student-preceptor relationship?

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In what ways can the SPH program staff help improve the practicum experience?

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Student signature: Date:

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