Field Placement Information and Agreement Form Step 1 of 4 25% Student InformationName* 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 Enrollment Status* Full time Part time On leave of absence Anticipated Graduation Date* Month Day Year Does this placement count as your degree program's required practicum or field experience?* Yes No Demographic InformationAs 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 the gender with which you identify:* Male Female Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Specify your ethnicity:* Hispanic/Latino Non-Hispanic/Non-Latino Specify your race:* American Indian/Native American Asian Black or African-American Native Hawaiian/Other Pacific Islander White More than one race 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 Reservist Veteran (prior service) Veteran (retired) What is your academic or training year?* Undergrad Year 3 Undergrad Year 4 Undergrad Year 5 Graduate Year 1 Graduate Year 2 Graduate Year 3 Graduate Year 4 Graduate Year 5 Graduate Year 6 Graduate Year 7 What type of degree program are you enrolled in?* Student - Graduate - Public Health Student - Graduate - Other Which of the following best matches your primary academic discipline?* Public Health - Disease Prevention & Health Promotion Public Health - Health Policy & Management Public Health - Environmental Health Public Health - Infectious Disease Control Public Health - Injury Control & Prevention Public Health - Social & Behavioral Sciences Do you intend to become employed or pursue further training in any of these settings? (Select all that apply.) Medically underserved community Primary care setting Rural setting None of the above Organization InformationSite Name* Department/Division* Address* Street Address City State / Province / Region ZIP / Postal Code Zip + 4*What type of site is this?* Academic Institution Acute Care Service Community Health Center Community Based Organization Hospital Local Health Department National Health Association State Health Department Is this site a...* primary care setting? medically underserved community? 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. Site Supervisor/Preceptor InformationName* First Last Job Title* Phone*Email* Field Placement InformationSemester of Placement* Fall Spring Summer Estimated Start Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Estimated End Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Project SummaryProject 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 placement. The requirements are listed below:• Student Placement Demographic Survey • Student Poster Presentation or Scientific Report • Student Final Evaluation • One Year Post-Placement Student Survey* I agree.
