This form must be submitted to the Practicum Coordinator before the student will be allowed to register. Please complete this form electronically; the text fields will expand as you type. Submit to the Practicum Coordinator, Jessica Pratt, via email () or fax 404-413-1489. Specific questions about the practicum should be addressed to the PhD Program Director.

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

Panther ID: Click here to enter text. Phone number: Click here to enter text.

Anticipated Graduation Term: Click here to enter text.

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

Title: Click here to enter text.

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

Address: Click here to enter text.

Email: Click here to enter text. Phone number: Click here to enter text.

Practicum Title: Click here to enter text.

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

Location: Click here to enter text.

Practicum Description

Describe the nature and scope of the proposed project: Click here to enter text.

Practicum Goals

In the table below, identify the types of activities you plan to undertake, any products you plan to develop, and indicate how you will assess your progress. Your activities should describe how you will demonstrate the competencies. Goals should follow the SMART convention: Specific, Measurable, Attainable, Relevant, and Time-Bound. (Fields will expand as you type.)
Competencies / Activities / Assessment
Understand the strengths and weaknesses of various epidemiologic study designs and research methods. / Click here to enter text. / Click here to enter text.
Demonstrate expertise in the ethical conduct of human subjects research, including confidentiality and vulnerable populations. / Click here to enter text. / Click here to enter text.
Critically review, synthesize, and evaluate the scientific literature and present appropriate implications for public health practice, public policy, and further research. / Click here to enter text. / Click here to enter text.
Demonstrate proficiency in epidemiological research by: (1) formulating a research question and/or corresponding hypotheses, (2) developing the study design, (3) participating in data collection, (4) conducting statistical analyses, and (5) interpreting scientific results. / Click here to enter text. / Click here to enter text.
Demonstrate mastery and independence as a researcher by pursuing and completing a specialized area of epidemiologic research. / Click here to enter text. / Click here to enter text.
Effectively present and disseminate findings from epidemiologicresearchto scientific and lay audiences. / Click here to enter text. / Click here to enter text.

Practicum Worksite & Resources

Describe the facilities, technologies, materials, or supplies that will be used by you (e.g. work space, access badge, data, processing applications, etc.). Provide the source and amount of funding, if any.
Click here to enter text.

AGREEMENT

I have participated in the development of the practicum proposal and agree to conditions (e.g. learning goals, preceptor) specified above. If it is necessary to change any of the specified conditions, I agree to make the changes known to each of the persons whose signatures appear below.

By signing, I also confirm that this practicum is separate and distinct from my regular duties, if completing at my place of employment.

Student signature: Date: ______

Preceptor signature: ______Date: ______

PhD Program Director signature: ______Date: ______

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