Field Placement Agreement Form

Field Placement Information and Agreement Form

Step 1 of 4

  • Student Information

  • In accordance with HRSA requirements, we need an email address to be able to contact you after graduation.
  • Demographic Information

    As a HRSA requirement, the Midwestern Public Health Training Center (MPHTC) must collect the following information from field placement students. Information will not be shared with your site preceptor. Please answer the following questions to the best of your knowledge.
    Definition: Rural is a geographical area that is NOT part of a Metropolitan Statistical Area. The general concept of a metropolitan area is that of a large population nucleus, together with adjacent communities having a high degree of social and economic integration with that core. Metropolitan areas comprise one or more entire counties, except in New England,where cities and towns are the basic geographic units.
    Definition: Disadvantaged Background is a citizen, national, or a lawful permanent resident of the United States or the District of Columbia, the Commonwealth of Puerto Rico or the Marianas Islands, the Virgin Islands, Guam, the American Samoa, the Trust Territory of the Pacific Islands, the Republic of Palau, the Republic of the Marshall Islands and the Federated State of Micronesia who either comes from: (1) an environment that has inhibited the individual from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a health professions school OR (2) a program providing education or training in an allied health profession OR (3) a family with an annual income below the level based on low income thresholds according to family size published by the U.S. Bureau of Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary, HHS, for use in health professions and nursing programs.