ClaremontGraduateUniversity
MasterofPublicHealth(MPH)
SupervisedFieldTraininginPublicHealth
Spring201______
Summer201______
Fall201______
Today’sdate:_______
AGENCYAPPLICATION
TOBEAFIELDPLACEMENTSITE
(Tobecompletedbythefieldsupervisor)
AgencyandDivision/Department/Program:
FieldSupervisor:
TitleofSupervisor:
AcademicDegreesEarned:
Address:
City: State: Zipcode:
Phone:
Fax:
E-mail:
AgencyWebsite:
Professionalspecialtyareas:
HowmanyMPHstudentscanyouracceptatanyonetime?
Anticipatedstartdateforanintern:
Mayprospectiveinternscontactyoudirectly?Yes/No
Isyouragencyabletoofferastipendorotherfinancialcompensationforthestudent?Yes/No/Unsure
Ifyes,provideanestimateofmonetaryorotherformofcompensation
AgencyApplicationforFieldPlacement
Page2
PleaseRANKona1-5scale(5high)thelearningopportunitiesavailablewithinyouragency:
Assessment
Needsassessmentofindividualsorcommunities
Determiningprogrampriorities
Collecting/analyzing&managingdata
Analysesofsocial,cultural,historicalcontextofproblem
Intervention
Programplanning/curriculumdevelopment
Planningworkshops,conferences
Providingtraining/publicspeaking/presentations
Settingprogramobjectives
Proposalwriting/grantsmanship
Marketing
Communityorganizing
Healthcommunications
Evaluationresearch
Policy:
Policyresearch
Advocacy
Interpretingregulations/programsfrompolicy
ProcessSkills
Department,agencyandcommunitymeetings
Consultation
Workingwithtechnology
Workingwithdiverseculturalandethnicgroups
Workingwithinterdisciplinaryteams/groups
OTHER:
Inyourestimation,whichtypeofsub-specialtyofpublichealthwouldthisexperiencebestsuit?Check
allthatapply.
______HealthPromotion/HealthEducation
______Leadership&Management
______Biostatistics/Epidemiology
______HealthInformatics
AgencyApplicationforFieldPlacement
Page3
Pleaseprovideabriefdescriptionoftheproject/assignmentsinwhichyouenvisionthestudent(s)being
involved.
Pleaselistminimumqualifications(previousexperienceorskills,languagesspoken)yourequireofa
studentforeachpositionavailable.Ifavailable,pleaseattachajobdescription.
Howwouldyoucategorizeyouragency?Pleasecheckallthatapply.
HealthDepartment(stateordistrict)
EducationalInstitution
IndianHealthService
OtherGovernmentEntities(city,county)
Hospital
CommunityClinic
Community-basedOrganization
ConsultingFirm
SocialServicesAgency
Foundation/ResearchInstitutions
Union/LaborOrganization
Industry/Insurance
HMO
PrivateVoluntaryOrganization
Military
TribalAgencies
EthnicSpecificTargetPopulation
Urban
Rural
Other
AgencyApplicationforFieldPlacement
Page4
Ifpossible,pleaseenclosethefollowingmaterials,whichwillhelptointroduceyourorganizationto
studentsintheMastersofPublicHealthProgram.
Ajobdescriptionforanypositionsimilartowhatthestudentmaybedoing
Amissionstatement&/orwrittenstatementofobjectivesforyourorganization
Anorganizationalchartofyourorganization
Brochuresorpamphletsonyourorganization
Brochuresorpamphletsonyoursponsoredprogramsand/orservices
Informationaboutyourcommunity.(e.g.,localnewspaper,maps,placeofinterest,etc).
Pleaseattachacopyofyourresume(omittinghomecontactinformation)forourfilesreview.
Note:Ideally,supervisorsshouldpossessanadvanceddegreeinpublichealthorrelatedfield.Ifnot,significantworkexperienceinpublic
healthmaybeanacceptablesubstitute.
Pleasereturnthisformto:
DarleenPeterson,PhD,MPH,MCHES
AssociateProfessor&Director
MPHProgram
ClaremontGraduateUniversity
675W.FoothillBlvd.,Ste.310
Claremont,CA91711
Phone:(909)607-6729
Fax:
(909)592-8411
e-mail:darleen.peterson@cgu.edu