Field Placement Information and Agreement FormStep 1 of 425%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 Academic Instruction Program Type* Enrolled in a campus-based program only Enrolled in a distance learning program only Enrolled in a hybrid programEnrollment Status* Full-time Part-timeAnticipated Graduation Date* Month Day YearDoes this placement count as your degree program's required practicum or field experience?* Yes NoDemographic 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 your gender.* Male FemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Specify your ethnicity.* Hispanic/Latino Non-Hispanic/Non-LatinoSpecify your race. (Select all that apply.)* American Indian or Alaskan Native Asian Black or African-American Native Hawaiian or Other Pacific Islander WhiteAre you from a Rural Residential Background?* Yes NoDefinition: 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 NoDefinition: 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 - retiredWhat is your academic year?*Undergrad Year 1Undergrad Year 2Undergrad Year 3Undergrad Year 4Graduate Year 1Graduate Year 2Graduate Year 3Graduate Year 4Graduate Year 5Graduate Year 6Graduate Year 7What type of degree program are you enrolled in?* Allied Health Behavioral Health Dentistry Medicine Nursing Public Health OtherWhich of the following best matches your primary academic discipline/specialty?*Community Health WorkerDental AssistantDental HygieneEMT/ParamedicHome Health AideMedical AssistantMidwife (non-nurse)Nutritionist/DieticianOccupational TherapyPhysical TherapyRehabilitation TherapySpeech Pathology/TherapyWhich of the following best matches your primary academic discipline/specialty?*Clinical PsychologyClinical Social WorkCounseling PsychologyMarriage and Family TherapyPastoral/Spiritual CareSubstance Abuse/Addictions CounselingWhich of the following best matches your primary academic discipline/specialty?*Dental Public HealthOral and Maxillofacial SurgeryOrthodontics and Dentofacial OrthopedicsPediatricWhich of the following best matches your primary academic discipline/specialty?*Aerospace MedicineAllergy and ImmunologyColon and Rectal SurgeryDiagnostic RadiologyEmergency MedicineFamily MedicineGeneral SurgeryGeriatric MedicineGeriatric PsychiatryIntegrative MedicineInternal MedicineInternal Medicine/Family MedicineInternal Medicine/PediatricsMedical GeneticsNeurological SurgeryObstetrics and GynecologyOrthopaedic SurgeryOtolaryngologyPathologyPediatricsPhysical Medicine and RehabilitationPreventive MedicinePreventive Medicine/Aerospace MedicinePreventive Medicine/Family MedicinePreventive Medicine/Internal MedicinePreventive Medicine/Occupational MedicinePreventive Medicine/PediatricsPreventive Medicine/Public HealthPsychiatryWhich of the following best matches your primary academic discipline/specialty?*Alternative/ComplementaryClinical Nurse Specialist (CNS)Licensed Practical/Vocational Nurse (LPN/LVN)Nurse AdministratorNurse AnesthetistNurse EducatorNurse MidwifeNurse Practitioner (NP)Nursing InformaticsPublic Health NurseRegistered Nurse (RN)Researcher/ScientistWhich of the following best matches your primary academic discipline/specialty?*BiostatisticsDisease Prevention/Health PromotionEnvironmental HealthEpidemiologyHealth EducationHealth Policy/ManagementInfectious Disease ControlInjury Control/PreventionNutritionSocial & Behavioral SciencesWhich of the following best matches your primary academic discipline/specialty?*ChiropracticFacility AdministratorHealth Informatics/Information TechnologyMedical Laboratory SciencesOffice/Support StaffOptometryPharmacyPodiatryProfession Not ListedVeterinary MedicinePhysician AssistantWhat are your post-internship/post-graduation intentions?*I intend to apply for NHSC Loan RepaymentI intend to become employed at a state local or tribal health departmentI intend to become employed in a public health/prevention settingI intend to become employed or pursue further training in a medically underserved communityI intend to become employed or pursue further training in a primary care settingI intend to become employed or pursue further training in a rural settingNone of the aboveOrganization InformationSite Name*Department/Division*Address* Street Address City State / Province / Region ZIP / Postal Code Zip + 4*What type of site is this?*Academic institutionAcute Care for the Elderly (ACE) UnitsAcute care servicesAerospace operations settingAmbulatory practice sitesAssisted Living CommunityCertified Community Behavioral Health Center (CCBHC)Community Behavioral Health CenterCommunity care programs for elderly mentally challenged individualsCommunity Health Center (CHC)Community Mental Health CenterCommunity-based organizationCritical Access HospitalDay and home care programs (e.g., Home Health)Dental ServicesDentist OfficeEmergency RoomExtended care facilitiesFederal and State Bureau of PrisonsFederal Government Office or AgencyFederal Government - OtherFQHC or look-alikeGeriatric ambulatory care and comprehensive unitsGeriatric Behavioral or Mental Health UnitsGeriatric consultation servicesHospiceHospitalIndependent Living FacilityIndian Health Service (IHS) siteInternational nonprofit/nongovernmental organizationLocal Government Office or AgencyLocal health departmentLong-term Care FacilityMobile Clinic/SiteNational health association or affiliateNurse Managed Health ClinicsNursing HomeOtherOther community health center (e.g., free clinic)Other Oral Health FacilityPhysician OfficeProgram of All Inclusive Care for the ElderlyResidential Living FacilityRural Health ClinicSchool-based clinicSenior CentersSpecialty Clinics (e.g., mental health practice/rehabilitation/substance abuse clinic)State Government Office or AgencyState Health DepartmentSurgery ClinicTribal Health DepartmentTribal OrganizationVeterans Affairs Hospital or clinicN/AIn 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 aboveA 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 SummerEstimated Start Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Estimated End Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Project 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 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.
