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Field Placement Agreement Form

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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*
- MPH
- MHA
- MS
- BA
- BS
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*
Month
Day
Year
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.)*
- American Indian or Alaskan Native
- Asian
- Black or African-American
- Native Hawaiian or Other Pacific Islander
- White
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?*
- Not a veteran
- Active duty military
- National Guard
- Reservist
- Veteran - prior service
- Veteran - retired
What is your academic year?*
What type of degree program are you enrolled in?*
- Allied Health
- Behavioral Health
- Dentistry
- Medicine
- Nursing
- Public Health
- Other
Which of the following best matches your primary academic discipline/specialty?*
Which of the following best matches your primary academic discipline/specialty?*
Which of the following best matches your primary academic discipline/specialty?*
Which of the following best matches your primary academic discipline/specialty?*
Which of the following best matches your primary academic discipline/specialty?*
Which of the following best matches your primary academic discipline/specialty?*
Which of the following best matches your primary academic discipline/specialty?*
What are your post-internship/post-graduation intentions?*

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Organization Information
Site Name*
Department/Division*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Zip + 4*
What type of site is this?*
In which of these areas will you be completing your field placement internship? (Select all that apply.)*
- Medically underserved community
- Primary care setting
- Rural setting
- None of the above
A medically underserved community is a geographic location or population of individuals that is eligible for designation by a state and/or the federal government as a health professions shortage area.
Please provide any additional information about the setting/community.

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Site Supervisor/Preceptor Information
Name*
First Last
Job Title*
Phone*
Email*
Field Placement Information
Semester of Placement*
- Fall
- Spring
- Summer
Estimated Start Date*
Estimated End Date*

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Project Summary
Project Title*
Description (Include activities, skills to be gained/used, population and area served):*
Learning objectives (What do you expect to know or be able to do following completion of the placement?):*
Field placement deliverables (What do you expect to provide as the final product(s) of your field placement work?):*
Preliminary project timeline:*
Include key activities and milestone dates.
By checking this box, you (the student) confirm that you will be participating in the field placement described above and that you will complete all the requirements to be eligible to receive the MPHTC student stipend ($3,500) at the end of your field placement. The requirements are listed below:• Student Placement Demographic Survey • Student Scientific Report • Student Final Evaluation • One Year Post-Placement Student Survey*
I agree.

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Acknowledgement: This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB6HP31688 “Public Health Training Centers Program.” This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

© Midwestern Public Health Training Center