Field Placement Agreement Form

Student Information

Name*

First Last

Phone*

School Name*

School Email*

Personal Email*

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

Degree Program*

Academic Instruction Program Type*

Enrolled in a campus-based program only
Enrolled in a distance learning program only
Enrolled in a hybrid program

Enrollment Status*

Full-time
Part-time

Anticipated Graduation Date*

Does this placement count as your degree program's required practicum or field experience?*

Yes
No

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.

Specify your gender.*

Male
Female

Date of Birth*

Specify your ethnicity.*

Hispanic/Latino
Non-Hispanic/Non-Latino

Specify your race. (Select all that apply.)*

Are you from a Rural Residential Background?*

Yes
No

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.

Are you from a Disadvantaged Background?*

Yes
No

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.

What is your veteran status?*

What is your academic year?*

What type of degree program are you enrolled in?*

Which of the following best matches your primary academic discipline/specialty?*

What are your post-internship/post-graduation intentions?*

Field Placement Agreement Form

Field Placement Information and Agreement Form

Step 1 of 4

Student Information

Demographic Information

Organization Information

Site Supervisor/Preceptor Information

Field Placement Information

Project Summary