IPHS 650: Field ExperienceRegistration Form/Learning Agreement
This form MUST be typed
STUDENT INFORMATION
Name: Click here to enter text. UIN #:Click here to enter text. SPH Division:Choose an item.
Phone:Click here to enter text. Email:Click here to enter text.
Online student: Dual degree student (MSW, MBA etc.):Click here to enter text.
FIELD EXPERIENCE/PRACTICUM REGISTRATION INFORMATION
Please note: When a student’s field experience occurs over at least 4 weeks of a semester registration for IPHS 650 is required. So some students might be required to register for this course for two semesters and can indicate that on this form. If a student needs to register for IPHS 650 for two semesters and doesn’t indicate that on this form, the second semester the studentwill have to email their field experience advisor who must approve the request to register for additional credit hours for the following semester. Then the email can be forwarded to Jaime at so the request can be processed.
Semester:Click here to enter text. Year:Click here to enter text.
Beginning Date:Click here to enter text. Ending Date:Click here to enter text.
Hours/Week on Site:Click here to enter text. Credit Hours:Click here to enter text.
Field Experience will continue into this semester…
Semester:Click here to enter text. Year:Click here to enter text.
Beginning Date:Click here to enter text. Ending Date:Click here to enter text.
Hours/Week on Site:Click here to enter text. Credit Hours:Click here to enter text.
Division Field Experience Advisor (different than Academic Advisor):Click here to enter text.
PRECEPTOR/ORGANIZATION INFORMATION (Please attach preceptor resume)
Name:Click here to enter text. Title:Click here to enter text.
Organization:Click here to enter text.Address:Click here to enter text.
Phone:Click here to enter text. Email:Click here to enter text.
Experience Paid: Unpaid:Are you currently working at the organization? Yes No
Is this an approved site on the official SPH list (if this experience is paid or you currently work there you can skip this question)?Yes
INSTITUTIONAL REVIEW BOARD (IRB)
Student activities involving human subject research must have approval from the Institutional Review Board before beginning data collection or analysis. Human subject research activities include surveys, interviews, analysis of pre-existing human subjects’ data and/or human tissue obtained for non-research purposes.Please check one of the boxes regarding IRB status: IRB Approval PendingIRB Approval Number: IRB Approval Not Required
LEARNING AGREEMENT
Provide a brief description of your overall learning goal. What do you want to learn as a result of participating in this field experience?
Field Experience Learning Objectives
A student must describe 2-4 specific learning activities to guide the student’s experience, which should be followed by a brief description of the deliverables/products/outcomes of those activities. Then the field experience learning objectiveslisted below should connect to the activities. Students have to list the number or numbers of the field experience learning objectives being addressed in that specific activity or activities.
Field experience learning objectives. Through the field experience students will be able to:
- Apply public health theory, knowledge and skills in a practice setting.
- Complete a defined project(s) in an area of public health practice including core public health functions such as assessment, program planning, program evaluation, policy development, educational campaign or applied research
- Relate the “realities” of public health practice-organizational structure, local and organizational politics, program administration, community relationships, program coordination-to their defined project(s).
- Demonstrate skills and knowledge in an area of interest not covered in depth elsewhere in their educational plan.
- Demonstrate competence in a public health practice area(s).
- Demonstrate leadership, teamwork, communication skills, and creativity in the development of public health practice activity.
EXAMPLE:
LearningActivity(ies):Manage the development of training courses by evaluating current courses and facilitating webinars.
Deliverable(s): Evaluation results,reports, presentations, and recordings of webinars.
Number(s) of FE learning objectives being addressed: 2, 3, 6
- Learning Activity(ies):Click here to enter text.
Deliverable(s): Click here to enter text.
Number(s) of FE learning objectives being addressed: Click here to enter text.
- Learning Activity(ies):Click here to enter text.
Deliverable(s): Click here to enter text.
Number(s) of FE learning objectives being addressed: Click here to enter text.
- Learning Activity(ies):Click here to enter text.
Deliverable(s): Click here to enter text.
Number(s) of FE learning objectives being addressed: Click here to enter text.
- Learning Activity(ies):Click here to enter text.
Deliverable(s): Click here to enter text.
Number(s) of FE learning objectives being addressed: Click here to enter text.
APPROVAL SIGNATURES Sign this document electronically, you can download amobile signature application.
Division Field Experience Advisor Date
PreceptorDate
StudentDate
International Students: International students must complete a Curricular Practical Training application, and submit the completed request to an advisor during open advising or by appointment.
Last date updated 01/18/2017