Public Health Practicum Student Manual

Transcription

1 Public Health Practicum Student Manual Revised May 2013 Grand Canyon University Master of Public Health Master of Science in Nursing with an emphasis in Public Health

2 Table of Contents Part I: Introduction...3 Goals of the Public Health Program... 3 Overview of Course Objectives and Prerequisites... 4 Planning Ahead for the Practicum Experience... 4 Selecting a Practicum Site... 4 Time Commitments to the Practicum Experience... 5 Practicum Fees... 5 Part II: Summary of Practicum Requirements for Public Health Students...6 Health/Safety Standards... 6 Resume... 6 Selection of a Preceptor... 6 Requesting Practicum Placement... 6 Orientation for Preceptor... 6 Professional Dress... 7 Evaluations... 8 Part III: Roles and Responsibilities...9 Responsibilities of the Office of Field Experience... 9 Responsibilities of the Practicum Site... 9 Role and Responsibilities of the Preceptor... 9 Part IV: Step-by-Step Directions for Practicum Approval...10 At Least 16 Weeks Prior to Beginning the Practicum Course At Least 8 Weeks Prior to Beginning the Practicum Course At Least 6 Weeks Prior to Beginning the Practicum Course At Least 2 Weeks Prior to Beginning the Practicum Course Part V: Required Practicum Forms...11 Fax Cover Sheet Practicum Application Medical Clearance Form HIPAA Confidentiality Agreement Practicum Site Information Form Student Acknowledgment of Practicum Guidelines Qualified Preceptor Form Weekly Practicum Experience Activities Log Preceptor Evaluation of Practicum Student Student Evaluation of Preceptor... 22

3 Part I: Introduction This manual is designed to provide information about the practicum experiences related to the Master of Public Health (MPH) program and the Master of Science in Nursing with an Emphasis in Public Health (MSN-PH). This document provides all the guidelines and forms necessary to meet programmatic requirements. It also serves as a Memorandum of Understanding between the student, practicum site, and Grand Canyon University. The practicum experience is an opportunity to develop and use the knowledge and skills acquired in the academic program in a public health agency or other environment in which a public health function is performed (e.g., health education programs in a health department or nonprofit organization, hospital infection control program, global health organization). This learning experience will allow students to become acquainted with the workplace environment, and will provide networking opportunities that could lead to employment following completion of the program. During the practicum experience, classroom assignments focused on introspection and identifying personal change, professional growth, and self-assessment will document professional development. Examples include the development of policy, the enhancement of communication skills, an understanding of public and private financing mechanisms, and a comprehension of organizational behavior and change. Grand Canyon University s Office of Field Experience is here to assist students in finding placements when they are unable to do so themselves. It is assumed that students have taken steps to ensure their practicum placements prior to beginning the practicum courses. It is an expectation of all Public Health students to actively seek placement. It is each student s responsibility to complete a satisfactory field experience that fulfills program requirements; the role of the practicum faculty is to guide and advise during the process. Once a completed practicum application has been submitted to the Office of Field Experience (OFE), the MPH program director will review proposed field placements and approve those that are appropriate. Goals of the Public Health Program The GCU MPH program is designed to draw on knowledge and skills from a variety of disciplines to define, assess and ultimately resolve public health problems. The primary goal of the program is to provide academic preparation for people interested in disease prevention and community health. Graduates of the GCU MPH program will be able to: 1. Collect, evaluate, manage, organize and effectively utilize public health data to produce meaningful actionable and credible information that can be used to inform public health services. 2. Articulate behavioral, social and cultural factors related to individual and population health and health disparities over the life course, utilizing research and practice in this area to develop, administer and evaluate of programs and policies. 3. Evaluate legal and social risks; determine education and communication strategies, develop and analyze alternative solutions, and develop effective health policies to advance public health goals. 4. Apply health program management and leadership knowledge and skills required in practice to ensure effective health policy, adequate consideration of the delivery, quality, and costs of health care for individuals and populations, and the ability to create and communicate a shared vision for a changing future; champion solutions to organizational and community challenges; and energize commitment to goals. 5. Apply knowledge, understanding, and consideration of the biological, physical, and chemical factors related to the environmental impact on the health of a community.

4 Overview of Course Objectives and Prerequisites HLT 660 Practicum Course and HLT-665: Public Health Practicum Course The practicum course is designed to provide students with an opportunity to transition from theory to practice. The student reinforces and integrates concepts, principles, and skills gained during coursework that are essential to professional competency. The practicum experience should relate to at least one of the core areas of public health: 1. Biostatistics collection, storage, retrieval, analysis and interpretation of health data; design and analysis of health-related surveys and experiments; and concepts and practice of statistical data analysis; 2. Epidemiology distributions and determinants of disease, disabilities and death in human populations; the characteristics and dynamics of human populations; and the natural history of disease and the biologic basis of health; 3. Environmental Health Sciences environmental factors including biological, physical and chemical factors that affect the health of a community; 4. Health Services Administration planning, organization, administration, management, evaluation and policy analysis of health and public health programs; 5. Social and Behavioral Sciences concepts and methods of social and behavioral sciences relevant to the identification and solution of public health problems Students are required to complete a minimum of 80 hours* of on-site work, under close supervision, during the practicum experience. Students are simultaneously enrolled in HLT 660 Practicum*. The practicum will be performed under the supervision of a faculty member and an on-site preceptor approved by the College of Nursing and Health Care Professions. *MPH students who newly enroll in the online MPH program on or after June 20, 2013, will be required to complete a minimum of 150 hours of practicum experience and enroll in HLT 665 Public Health Practicum course *MSN-PH students who newly enroll in the online MSN-PH program on or after June 13, 2013 will be required to complete a minimum of 150 hours of practicum experience and enroll in HLT 665 Public Health Practicum course. * MPH students who newly enroll in the ground MPH program will be required to complete a minimum of 150 hours of practicum experience and enroll in HLT 665 Public Health Practicum course Prerequisites for the course are: HLT-605 and Completion of all previous didactic coursework with a passing grade GPA of 3.0 or better Submission of all required practicum documents to the Office of Field Experience prior to the deadlines indicated Approval of the practicum placement from the Office of Field Experience Planning Ahead for the Practicum Experience Students should identify an interest area or focus for their practicum and schedule a time to meet with practicum faculty to discuss potential placement options in the area of focus. For assistance in identifying practicum faculty, please contact the Office of Field Experience. In order to have all the required clearances and releases in place to start the practicum course, students must initiate a formal application for the practicum experience with the Office of Field Experience at least 16 weeks prior to the date that they plan to begin the practicum course. The student s first step is to contact their GCU academic counselor to determine the start date of their practicum course. In certain circumstances, students may receive approval for a non-u.s. training site, provided that it has an identified preceptor who is willing to comply with GCU policies and procedures. However, requests for a non- U.S. training site must be submitted in writing to the MPH program director for review. This request must also include a written proposal that contains information about the training site and preceptor information. Selecting a Practicum Site Approved practicum sites may include health departments or other governmental agencies, medical centers,

5 community-based organizations, faith-based organizations, health-related nonprofit organizations, related private industry, community-based research projects, or research centers. Sponsoring sites designate a qualified member of their staff to serve as the student s preceptor. Preceptors will guide the student s experience on site, helping him or her think critically about the meaning of activities, while facilitating interactions with staff and community members.

6 Time Commitments to the Practicum Experience Students should plan ahead to meet the commitments of the practicum experience. Most host organizations are often limited to daytime and weekdays for providing practicum hours, and if the student does not complete 80 hours* of work during the practicum course, they will not be able to move on to the final capstone portion of the program. Additionally, if students do not complete a minimum of 80 hours* of practicum experience during the practicum course, they will have to enroll in additional credits of practicum coursework to complete the degree. Practicum students must complete all of their professional time commitment to the host agency even if they have successfully completed their logged clock hour commitment. Students must discuss, and agree upon, their practicum experience start and end dates with their preceptor. It is important for students to confer with the preceptor on how they will be expected to provide closure to their assigned projects. Please Note: Failure to complete the required minimum hours or failing to properly document completed hours for the public health practicum will result in failure of the course. *MPH students who newly enroll in the online MPH program on or after June 20, 2013, will be required to complete a minimum of 150 hours of practicum experience and enroll in HLT 665 Public Health Practicum course *MSN-PH students who newly enroll in the online MSN-PH program on or after June 13, 2013 will be required to complete a minimum of 150 hours of practicum experience and enroll in HLT 665 Public Health Practicum course. * MPH students who newly enroll in the ground MPH program will be required to complete a minimum of 150 hours of practicum experience and enroll in HLT 665 Public Health Practicum course Using a Current Place of Employment to Complete the Practicum Experience Students planning to use their current place of employment to complete their practicum must inform the Office of Field Experience that this is their intention, and obtain approval from the MPH program director in advance of the start date. If students already have paid employment with a host agency, their hours can be logged only after they have been approved and begun a practicum course. Students must be able to define a project for their practicum that is distinct from their day-to-day employment duties, with specific goals and objectives defined. Practicum Fees Generally, the cost of the practicum is the cost of the regular University tuition and fees. All University fees will be collected by the University business office. No fees will be paid to the preceptor or hosting agency. Practicum students are responsible for their own transportation and fees pertaining to any background fingerprint checks which may be required by the host site. Additional fees may be incurred by the student if a site requires vaccinations, chest x-rays, or other medical clearances. Though students are not required to join a professional organization, this practice is encouraged. Examples of organizations that students could consider joining include the American Public Health Association (APHA) and/or State Affiliates of the APHA. Each of these organizations offer discounted membership rates for students. Benefits can include learning more about public health work across the country, networking with public health professionals, opportunities to attend local and national conferences, and staying up-to-date on public health news. For more information, visit

7 Part II: Summary of Practicum Requirements for Public Health Students The following requirement must be submitted as directed prior to registration for HLT-665: Health/Safety Standards Health Clearance Form Proof of health insurance Signed HIPPA confidentiality statement at the end of this packet and submit via designated Angel drop box to the course faculty Other Health and Safety Requirements may be required by your individual sites, please contact the Office of Field Experience with further questions regarding additional requirements. Resume A one-page synopsis of education, work history, and pertinent practicum experience to have been included in application process. Share a copy with your preceptors prior to beginning clinical at the various sites. Selection of a Preceptor The preceptor must work in some area of public health Have a minimum of two years of health care or public health related experience Be committed to continual professional improvement. Able to provide an educational experience that will help the student meet their overall practicum objective and personal learning objectives. Readiness to allow students to gain experience in planning, delivering, and evaluating educational events. Preceptor willingness and time available to mentor students learning by serving as a resource during the practicum time. Provide opportunities to work with other health care providers as appropriate to augment the student s practicum experience. Requesting Practicum Placement Discuss the above outlined standards and practicum objectives with the potential preceptor. Provide the preceptor with a copy of the practicum objectives. If the practicum site requires an additional contract in addition to the Memorandum of Understanding the College of Nursing and Health Care Professions must be notified and will initiate the contract process Upon the completion of the aforementioned events a site is approved Orientation for Preceptor The student will provide the preceptor with the Practicum description and course objectives, and refer the preceptor to the course faculty to answer questions about the responsibilities and role of precepting. The student will follow the institution s dress code and professional behavior and will provide credentialing information as requested. The student will determine the protocol for notifying the preceptor of an unexpected absence. Failure to notify the preceptor prior to the beginning of the scheduled practicum is unacceptable and may place the student s practicum placement in jeopardy. Ensure that Grand Canyon University has all the required student and preceptor credentials on file prior to entering the clinical setting. Learn something about the preceptor, when possible, in order to acknowledge the preceptor s background such as preceptor education, work experience, community, and practice as ways to broaden the student s educational experience.

8 Professional Dress Students are expected to serve as professional representations of Grand Canyon University during their practicum experience. Please dress appropriately according to your individual site s requirements. GCU Nametags: Public Health students are expected wear an official nametag during their practicum. Students can call the GCU Bookstore Call Center ( ) to order the nametag. It takes approximately 2-3 weeks for the company to mail the name. At that time, the college will ship them out. The total cost to students is $13.00 plus $5.95 for shipping and handling plus tax. The name pin should state: First Name Last Name Public Health Student Grand Canyon University Professional business attire Practicum objectives Review the objectives as outlined in the respective course syllabus Practicum objectives must be measurable, reflect on the level of competency the student would like to achieve at the end of the practicum component of the respective course, and be congruent with and complement the course objectives. Practicum Hours Students are expected to schedule hours at the convenience and availability of the preceptor. The student s personal and work schedules are expected to accommodate the preceptor s schedule. Performance of hours at the negotiated times and day with the preceptor is required. In the event the student cannot attend a scheduled practicum day, the student must notify the preceptor prior to the experience. Determine the acceptable procedure for notification. Students are responsible to consult with their preceptors on any concerns and organizational issues that the student addresses. Evaluation Evaluation of the Student by the Preceptor The preceptor will be providing formative evaluation or ongoing evaluation over the course of the semester. This feedback can foster self-confidence, as well as identify areas needing improvement. At the end of the clinical practicum experience, the preceptor will be doing a summative evaluation or summary evaluation of your performance. The preceptor will complete the Evaluation of Student by Preceptor form. Students need to provide their preceptor with these forms at the beginning of the practicum experience. Prior to submission the preceptor will verbally provide feedback to student as to your strengths and areas to strengthen. The course and individual student learning objectives are to be reviewed within this meeting. It is often helpful to have the students complete a self-evaluation to compare with the preceptor s evaluation at the summative evaluation meeting. Both preceptor & student must sign the form before electronic submission to the faculty. Faculty Contact with your Preceptor The course faculty will oversee your practicum performance. The course faculty member for the practicum course will make periodic contact (telephone or ) as needed during the practicum course, at least at the beginning of the practicum and at some other point throughout the course. The preceptor is encouraged to contact the course faculty at other times if necessary. The course faculty will maintain in contact with the preceptor throughout the practicum course.

9 Evaluation of the preceptor and clinical site The student is to evaluate their preceptor (s) and the site at the end of the practicum experience/course. The purpose is to provide feedback on the effectiveness of the preceptor and site in facilitating the student to meet the learning objectives. Do this by filling out the Evaluation of Preceptor and Site by Student form (located in Loud Cloud Classroom). Submit electronically to the course faculty as directed. Verbally provide feedback to the preceptor regarding your satisfaction with the learning experience. Other Preceptor Thank You Certification Students are encouraged to provide the preceptor with a professional letter thanking them for their guidance during your practicum experience. Students may want to leave a copy of a positive preceptor evaluation with the preceptor for the preceptor to use in their own performance review.

10 Part III: Roles and Responsibilities Responsibilities of the Office of Field Experience The GCU Office of Field Experience (OFE) will determine if students have met all of the application requirements necessary to begin the practicum course. Additional responsibilities of the OFE manager are as follows: Ensure that students pursuing the practicum experience understand the nature of the program and the expectations involved. Assist students in the practicum application process if required. Be available to counsel with the student as situations dictate. Communicate with the practicum classroom instructors as necessary. Responsibilities of the Practicum Site Designate a professionally qualified individual to be the preceptor for the student. Provide the student with guidance and related experiences that meet the required number of practicum hours and experiences. Provide the student with an opportunity to learn about the organization s program and management functions, and to develop organizational insight into the mission and activities of the organization. Provide a meaningful orientation for the student regarding the host organization s purpose, services, organizational structure, and operating practices. Provide for student contact with appropriate staff members and clients. Make available space, supplies and other resources needed for carrying out the student s task assignments. Conduct evaluations in accordance with the student s program requirements. Provide a copy to the student and to the Office of Field Experience. Ensure the student operates within the appropriate ethical, organizational, professional, and legal guidelines appropriate to the setting. Notify the Office of Field Experience immediately in the event the student s performance becomes unsatisfactory. Role and Responsibilities of the Preceptor Serves as the practice liaison with the student while representing the organization or agency where the practicum is carried out. Provides instruction and guidance related to assigned tasks and projects. Provides support for professional development. Provides feedback to the supervisee that is timely, clear and specific, i.e., feedback is delivered soon after an important event and is based on specific performance criteria. Ensures a safe work environment. Challenges practice which the supervisor judges to be unethical, unwise, or incompetent. Challenges personal or professional blind spots which the preceptor may perceive. The preceptor should also: Orient the student to the work situation and be available on a daily basis for consultation as needed. Participate in the development of the student's plan for the practicum experience. Furnish the student with all the required signatures and documentation necessary to maintain and complete the student's file.

11 Part IV:Step-by-Step Directions for Gaining Approval to Begin the Practicum Experience Each prospective student is responsible for the timely fulfillment of the following application process. At Least 16 Weeks Prior to Beginning the Practicum Course 1. Students must identify one preferred and two alternative sites where they may want to conduct the practicum. Grand Canyon University s Office of Field Experience is here to assist students in finding placements when they are unable to do so themselves. It is assumed that students have taken steps to ensure their practicum placements prior to beginning the practicum courses. It is an expectation of all Public Health students to actively seek placement. The practicum sites must provide appropriate learning opportunities for the application of knowledge (theory, methodology, and research) and skills to practice the development of professional competence. The sites must provide appropriate facilities to enhance learning (e.g., adequate workspace, access to telephone and computers for site-related work). If necessary, the Office of Field Experience can help the student make contact with any agencies in which they are interested). 2. Prepare and submit a Practicum Application via fax or to the Office of Field Experience for review. Completion of this form will assist in clarifying the student s needs and goals for the practicum experience and will help identify an appropriate practicum experience placement. 3. Confirm eligibility with the Office of Field Experience and the MPH program director. 4. Prepare resume and cover letter for site interviews. 5. Interview with potential site supervisor(s). Questions that students should ask in the interview include: What is the overall mission of the host agency? (A brochure, mission statement, or purpose statement would be helpful.) What is a brief history of the organization? What is the structure of the organization (e.g., local, national, private, public, nonprofit or profitmaking, church-related, affiliating organizations, if any, etc.)? What is the planning process of the organization? What roles do this agency s employees with graduate degrees in public health have? How is one s performance reviewed? What are the major problems and difficulties encountered by this organization? What, if any, career development opportunities are available? At Least 8 Weeks Prior to Beginning the Practicum Course and Experience 1. Select a site. Once the student has received confirmation that a potential site has agreed to provide the practicum experience, A Site Information Sheet, Preceptor Information Form" and Acknowledgement of Practicum Guidelines should be completed and ed or faxed to the Office of Field Experience by the student for approval of the practicum site. 2. Confirm with the Office of Field Experience that the site is approved. If you change sites you must repeat the site approval process described in this manual. At Least 6 Weeks Prior to Beginning the Practicum Course and Experience 1. Complete any necessary site requirements that might be required by your site (e.g., contracts, vaccinations, fingerprints, chest x-rays). Two Weeks Prior to Beginning the Practicum Course and Experience 1. Confirm start date, times and practicum plan with site supervisor.

12 Required Practicum Forms Practicum students must use the following forms to complete the practicum application process and to document their practicum activities. Most of these forms will also be located in your online classroom. Cover Sheet to be included with all document submissions. 1. Practicum Application Form 2. Site Information Sheet 3. Preceptor Information Sheet 4. Acknowledgement of Practicum Guidelines as stated in the Public Health Practicum Manual. 5. Activity Log 6. Preceptor Evaluation form 7. Student Evaluation of Preceptor form All completed forms should include a cover sheet and be submitted by the method requested: Fax: Nicole.Dailey@gcu.edu Phone 1: Phone 2: Ext **If you need help with any portion of the practicum process appointment times may be scheduled by calling the Office of Field Experience.

13 To: Nicole Dailey FAX #: CONHCP Grand Canyon University PUBLIC HEALTH STUDENT FACSIMILE: HLT 660/HLT-665: Required Practicum Documentation Student Name: Student ID #: Student Contact Number: Date: Student GCU Anticipated HLT 660/HLT-665 Start Date: The following required documentation is being faxed with this cover sheet: Practicum Application Acknowledgement of Practicum Guidelines Signed HIPAA Form Medical Clearance Form Site Information Sheet Preceptor Information Sheet Preceptor s Evaluation of Practicum Student Weekly Practicum Experience Activities Log Student s Evaluation of Preceptor The deadline to submit your required documentation is sixteen weeks prior to the start date. Documentation submitted late will result in a later registration of the practicum course. Please submit your documentation early to avoid a delay in your practicum start date.

14 Student Name: Practicum Application To be prepared by the student and electronically submitted to the Office of Field Experience at least 16 weeks prior to registering for the practicum course. Student ID#: Address 1: Address 2: City: State: Zip: Alternate Address (other than my.gcu.edu): Phone (H): (W): (Cell): Program of Study (circle one): Master of Public Health or Master of Science in Nursing with an emphasis in Public Health Total Semester Hours Completed: Anticipated Start Date of Practicum: (obtained from academic counselor) Name of Preferred Host Agency: Address 1: Address 2: City: State: Zip: Type of Host Agency: Proposed Preceptor s Name: Preceptor s Position: Preceptor s Credentials: Preceptor s Degrees: Preceptor s Phone: Address of Preceptor: Name of Alternative Site #1: Contact Name: Contact Phone: Name of Alternative Site #2: Contact Name: Contact Phone:

15 What contacts and or arrangements, if any, have you already made with the preferred host agency? Describe any proposed practicum duties or tasks that you have already discussed with your proposed preceptor (if any). Date Submitted to the Office of Field Experience:

16 Medical Clearance Form STUDENT DETAILS Name: Date of Practicum Start: PRACTICE OFFICE DETAILS Name: Number: Address: Phone Number: MEDICAL CLEARANCE This student is in adequate health to provide services in a direct contact clinical/practicum environment. This student presents concerns that may be a potential risk to the student or others. Please explain: ADDITIONAL COMMENTS MEDICAL PRACTITIONER S DETAILS Signature: Printed Name: Date:

17 HIPAA Confidentiality Agreement Name (Please Print): The discussions, uses and disclosures addressed by this agreement mean any written, verbal or electronic communications. I understand that I am never to discuss or review any information regarding a patient at a clinical site unless the discussion or review is part of my assignment to the site. I understand that I am obligated to know and adhere to the privacy policies and procedures of the clinical site to which I am assigned. I acknowledge that medical records, accounting information, patient information and conversations between or among healthcare professionals about patients are confidential under law and this agreement. I understand that, while in the clinical setting, I may not disclose any information about a patient during the clinical portion of my clinical assignment to anyone other than the medical staff of the clinical site. I understand that I may not remove any record from the clinical site without the written authorization of the site. Additionally, I understand that, before I use or disclose patient information in a learning experience, classroom, case presentation, class assignment or research, I must attempt to exclude as much of the following information as possible: Names Geographical subdivisions smaller than a state Dates of birth, admission, discharge, and death Telephone numbers Fax numbers addresses Social security numbers Medical record numbers Health plan beneficiary numbers Account numbers Certificate/license numbers Vehicle identifiers Device identifiers Web locators (URLs) Internet protocol addresses Biometric identifiers Full face photographs Any other unique identifying number, characteristic, or code All ages over 89 years Additionally, I acknowledge that any patient information, whether or not it excludes some or all of those identifiers, may only be used or disclosed for health care training and educational purposes at Grand Canyon University, and must otherwise remain confidential. I understand that I must promptly report any violation of the clinical site s privacy policies and procedures, applicable law, or this confidentiality agreement, by me, or a Grand Canyon University student or faculty member to the appropriate Grand Canyon University clinical coordinator or program director. Finally, I understand that if I violate the privacy policies and procedures of the clinical site, applicable law, or this agreement, I will be subject to disciplinary action. By signing this agreement, I certify that I have read and understand its terms, and will comply with them. Signed: Date:

18 Public Health Practicum Site Information Form Student Name: Student ID#: Program of Study (circle one): Master of Public Health or Master of Science in Nursing with an emphasis in Public Practicum Course: HLT 660/HLT-665 Site Name: Address 1: Address 2: City: State: Zip: Type of Host Agency: Hours of Operation: Preceptor s Name: Preceptor s Position: address of Preceptor: Phone number of Preceptor: The practicum site must be of a nature and type that is approved for practicum hours and must relate to at least one (or more) of the core areas of public health biostatistics, epidemiology, environmental health, administration/policy, social & behavioral sciences. Please describe how this site complies (and the population(s) that it impacts). Describe how the practicum site provides appropriate learning opportunities for the application of knowledge (theory, methodology, research), skills to practice, and the development of professional competence, including appropriate facilities to enhance learning (adequate workspace, access to telephone and computers for siterelated work).

19 Student Acknowledgement of Practicum Guidelines Student: I,have read the guidelines for practicum as stated in the Public Health Practicum Manual and I agree to abide by them. Student Signature: Date: Preceptor: I understand the guidelines for practicum as stated in the Public Health Practicum Manual. have read and Preceptor Signature: Date: 18

20 Qualified Preceptor Form Student Name: Student ID#: Program of Study (circle one): Master of Public Health or Master of Science in Nursing with an emphasis in Public Health Site Name: Address 1: Address 2: City: State: Zip: Preceptor s Name: Preceptor s Title: Preceptor s Phone Number: Address of Preceptor: Preceptor s Credentials: Number of Years Experience in the Field: Have you Supervised Master s-level Practicum Students in the Past? YES NO If so, for how Many Semesters? Education: Institution and Division/School: Major: Highest Degree Earned: Please attach a copy of the most recent license/certification, if applicable. Year of Graduation: Preceptor s Signature: Date: 19

21 Student Name: Weekly Practicum Experience Activities Log Student ID#: Practicum Course: HLT 660/HLT-665 Week # Start Date: End date: Site Name: Preceptor s Name: Describe Duties Mon Tue Wed Thu Fri Sat Sun Total Total Hours for the Week: Required Signatures: Student (signature required each week) Date Preceptor (signature required each week) Date 20

22 Preceptor Evaluation of Practicum Student This form must be completed by the Preceptor and faxed / ed to the Office of Field Experience within 5 business days of completion of the practicum course. Student Name: Practicum Course: HLT 660/HLT-665 Site Name: Preceptor s Name: Student ID#: Evaluation Start Date: Evaluation End Date: Evaluation Metrics and Scale Not Observed Poor Below Average Average Above Average Superior Understanding of Administrative Processes Understanding of Public Health Objectives Understanding of Public Health Policy Considerations Understanding of Public Health Program Implementation Understanding of Public Health Impact Ability to Work With Partners Ability to Work With Clients Ability to Work With Co-Workers Respectful Self-Motivated Emotional Maturity Listening Skills Analytical Skills Verbal Skills Written Skills Ability to Contribute With Meaningful Suggestions Comments: Required Signatures: Student Date Preceptor Date 21

23 Student Evaluation of Preceptor This form must be completed by the student and faxed/ ed to the Office of Field Experience within 5 business days of completion of the practicum course. Student Name: Practicum Course: HLT 660/HLT-665 Site Name: Preceptor s Name: Did you receive weekly supervision? YES NO Student ID#: Evaluation Start Date: Evaluation End date: Evaluation Metrics and Scale Not Observed Poor Below Average Average Above Average Superior Quality of the Supervision Provided Provided Clear and Consistent Expectations Approachable Professional Ethics Respectful to You Respectful to Clients Respectful to Staff Teaching Ability Overall Supervision Experience What was the most helpful\useful part of your practicum experience? What areas and/or experiences in your practicum could have been better? Additional Comments: Required Signature: Student Date 22