225 Scott Bioengineering Building
Fort Collins, CO 80523-1376
970/491-7077
http://www.engr.colostate.edu/sbme
Student Agreement
In order for your practicum/independent study request to be fully evaluated, please carefully read
and complete all parts of this packet. Incomplete submissions will not be reviewed. Please type
all information in 11-point or larger font and submit pages 1 - 9 as soon as possible and at
least two weeks prior to the start of the semester for which you would like credit. Late
submissions will not be accepted.
Pages 9 – 22 must be submitted to your adviser in the School of Biomedical Engineering at
different times during the practicum/independent study experience. Please submit these to your
adviser in a timely manner. Late or missing submissions will adversely affect your grade.
As you complete this packet of information, please be as clear and concise as possible. Your
adviser will review this before submitting it for formal review, so explain your proposal in layperson’s terms so that we can understand what you are doing, how it applies to BME, and how
you will measure your progress. If we may be of assistance at any time, please do not hesitate to
contact us. We want this experience to be a very personally rewarding one for you.
Brett Eppich Beal
Adviser, BME major students (M-Z)
School of Biomedical Engineering
Brett.Beal@Colostate.edu
970-491-7077
Debra Misuraca
Adviser, BME Major (A-L) and Minor students
School of Biomedical Engineering
Debra.Misuraca@Colostate.edu
970-491-2557
*I have read the above statement and agree to all terms as stated.
Student Signature ______________________________________________________________
(Must hand sign –no typed signatures please)
Student ID # ___________________________________________________________________
Date ________________________________________________________________________
1
Rev 2-1-2016
School of Biomedical Engineering
Health Insurance Notification
Depending on the type of practicum/independent study you are in (paid vs. unpaid), you may not
be covered by Workers Compensation in the event you are injured.
○ If you are working at and being paid by a private company (other than CSU), the company is
responsible through the Workers Compensation program to provide medical care to you in the
event you are injured.
○ If you are working at and being paid by CSU, CSU is responsible through the Workers
Compensation program to provide medical care to you in the event you are injured.
○ If you are not being paid while working at a private company (other than CSU), and you are
enrolled in CSU credit, you will be covered under the CSU Workers Compensation program.
○ If you are not being paid and are working at CSU, you are responsible for your expenses if
injured. It is highly recommended that you have your own medical insurance to cover any injury
that may occur on the job.
If you should cause injury to someone else during your practicum experience, you are covered by
the University for liability since you are a CSU student. However, liability insurance does not
cover you if you are injured.
I have read this form and understand the terms of being involved in the practicum course. I am
aware that I may need to be covered under my own medical insurance in the event of injury.
Signature of Student ____________________________________________________________
Date _________________________________________________________________________
2
Practicum/Independent Study Interest Form
Turn into the SBME Office at least two weeks prior to start of term for which you desire credit.
NOTE: You may not do the work proposed in one term and get credit for it another term.
Date _______ /________/________
Full Name_____________________________________________________________________
CSU ID _______ - _______ - ________ Email Address _______________________________
Local Phone # (_____) _________ - _________
Cell # (______) _________ - ___________
Local Address _________________________________________________________________
City ______________________________________ State ________ Zip ___________________
Expected Graduate Date:
Fall ____________ Spring _____________ Summer ___________
___ Biomedical Engineering Bachelor’s Degree student with ____ CBE
____ EE
___ Biomedical Engineering Minor student with
______Engineering Major of _________________
______Non Engineering Major of ______________________________
___ Graduate Student: ____MS Student
____ ME Student
___ MECH
_____ PhD Student
Intended Semester for Practicum/Independent Study: Fall ______ Spring ______ Summer _______
Course Desired: ______ BIOM 476 A (2 credits)
_____ BIOM 476B (4 credits)
______ BIOM 495 (__ 1 __ 2 __ 3 __ 4 __5 __ 6 credits)
For the BME undergraduate programs, a total of 3 credits is allowed for BIOM 476 or 495.
Credit hour requirements: 3 - 4 hours/week are required per credit for a 15-week semester.
Thus, 1 cr = 45 – 60 hours/semester; 2 cr = 90 – 120 hours/semester; 3 cr = 135 – 180 hours/semester.
The time per week will need to be adjusted for any summer courses; overall hours will be the same,
though more hours per week may be required.
3
Practicum/Independent Study Intake Form
Complete the information and return to the School of Biomedical Engineering (225 Scott Bioengr Bldg)
BEFORE you accept an offer for this credit-bearing practicum/independent study.
Date: _____________
Name: ________________________________________________________________________
CSU Student ID: _______________________________________________________________
Academic Term for which you wish to receive credit (semester and year): __________________
Email: _______________________________________________________________________
Home/cell phone number: ________________________________________________________
Major: ________________________________________________________________________
Practicum/Independent Study Site Information
Payment Status (paid/unpaid): ____________________________________________
Pay rate: ______________________________________________________________________
Student job title: ________________________________________________________________
Number of hours worked per week: _________________________________________________
Start Date: ____________________________Termination Date: _________________________
Company Information
Company/Agency Name: _________________________________________________________
Address: ______________________________________________________________________
City: __________________________________________________ State _____ ZIP_________
Supervisor Name and title: ________________________________________________________
Phone number: ___________________________ FAX: _______________________________
Company website: ______________________________________________________________
4
Practicum/Independent Study Scope of Work
Please complete this information and return to the School of Biomedical Engineering for practicum/independent
study approval before accepting a practicum/ /independent study offer.
1) Explain in detail what you will be doing. Please attach a separate page if needed.
2) Explain how your activities and goals for this course relate to biology or medicine.
3) Explain how your activities and goals for this course relate to engineering.
4) State your learning objectives (which need to be measurable and specific), and how you will
measure if you’ve learned them. You may use the chart on page 6 if you’d like. Your objectives
should be clear, concise, and consistent with the activities, responsibilities and expectations
described in this packet. Typically, there will be at least one learning objective per credit hour.
5) Agree to produce a final written report that addresses at least how well you met your learning
objectives and supports conclusions you make in this area with data.
6) Get your mentor (practicum supervisor) to agree to write a one-page letter of evaluation
stating what you did and how well you met the learning objectives.
5
Student Responsibilities and Expectations
To be completed by the Practicum Supervisor and student.
Please list student’s responsibilities and both student and faculty expectations of practicum
experience:
STUDENT SIGNATURE ___________________________________________________
SIGNATURE OF ____________________________________________________
PRACTICUM SUPERVISOR
6
Summary of Learning Objectives (LOs)
In terms understandable by your academic adviser, please complete the table below. Feel free to
expand the boxes below to fit a clear, concise and easily understood explanation. Summary of
Learning Objectives (LOs)
In terms understandable by your academic adviser, please complete the table below. Feel free to
expand the boxes below to fit a clear, concise and easily understood explanation.
Learning
Objective (LO) –
this is the “goal”
with some kind of
measurable
outcome.*
Example:
“Record EEGs
and EMGs from
human subjects”
What project activities,
How will achievement of this
expectations and/or responsibilities LO be assessed and who will
support this LO? Be sure to include assess it?
the mechanisms or methods that will
be used to achieve the LO.
Example: “The expectations include
accurately recording EEG and
EMGs from human subjects.”
Example: “Supervisor will
observe and evaluate student’s
ability to record EEG and EMG
data from human subjects.”
*Think of this as a sentence that starts with “Student will be able to/(insert action verb here)…..So, in the example
above, “Student will be able to record…”
7
Checklist of Forms Turned In
This is to help you keep track of forms and paperwork you’ve submitted.
You do not turn this into the SBME Office.
Practicum/Independent Study Intake Form
Date submitted: _____________
Health Insurance Notification Form
Date submitted: _____________
Tentative Work Schedule
Date submitted: _____________
Practicum/Independent Study Bi-Weekly Reports
Date submitted: _____________
Practicum/Independent Study Midterm Student
Self-Evaluation Form
Date submitted: ____________
Midterm Practicum/Independent Study Evaluation
of Student by Practicum Supervisor
Date submitted: ____________
Final Practicum/Independent Study Report
of Student by Practicum Supervisor
Date submitted: ____________
Final Practicum/Independent Study Evaluation
of Practicum Experience by Student
Date submitted: ____________
Final Presentation or report
Date presented: ____________
8
TENTATIVE WORK SCHEDULE
Complete and give copy to practicum/independent study supervisor, copy to the SBME Office, and keep copy for
your records.
STUDENT NAME: ________________________________________________
MONDAY
TUESDAY
WEDNESDAY
8:00
9:00
1 10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
9
THURSDAY
FRIDAY
SATURDAY
STUDENT WEEKLY REPORT
To be completed by the student at the end of each week. These reports are due bi-weekly to
the SMBE office on the dates listed in your plan. The reports should be reviewed and signed by
your practicum/independent study supervisor. You are encouraged to discuss any experiences
and problems with your supervisor and/or academic adviser and incorporate any suggestions
offered. You are welcome to make copies of this report to assist you with your written reports.
DATES OF REPORT _____________________ TO ________________________________
STUDENT NAME ____________________________________________________________
SIGNATURE OF SUPERVISOR _______________________________________________
TOTAL HOURS FOR THE WEEK ______________________________________________
SHORT DESCRIPTION OF PRACTICUM/INDEPENDENT STUDY ACTIVITIES
MONDAY
TUESDAY
WEDNESDAY
10
THURSDAY
FRIDAY
WEEKEND
Supervisor Comments:
11
PRACTICUM/INDEPENDENT STUDY MIDTERM EVALUATION FORM
School of Biomedical Engineering
Student Self-Evaluation
This MUST be completed and turned into the SBME Office at the midpoint of the term.
Instructions: To be completed by the student. Please return to the SBME office before review
with practicum/independent study supervisor.
Please use the rating scale listed below to evaluate yourself in the areas indicated on the attached
sheet.
Circle Course Number: BIOM 476A (2 cr) BIOM 476B (4 cr) BIOM 495 (1 2 3 4 5 6 cr)
STUDENT NAME: _____________________________________________
Rating Scale:
Outstanding…………………few other students equal
Good………………………..above most other students
Average……………………..as expected for age and experience
Poor…………………………inferior
N/A………………………….not applicable
STUDENT SIGNATURE: _________________________________________________
12
PRACTICUM/INDEPENDENT STUDY MIDTERM EVALUATION FORM
School of Biomedical Engineering
Student Self-Evaluation
STUDENT NAME ________________________________________________
DATE __________________________________
Technical Knowledge
General Education/
Technical
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
______
Life Sciences
____
____
_____
_____
_______
Engineering
____
____
_____
_____
_______
Leadership Qualities
Initiative
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
______
Confidence
____
____
_____
_____
_______
Resourcefulness
____
____
_____
_____
_______
Originality
____
____
_____
_____
_______
Ability to Analyze Problems
____
____
_____
_____
_______
Adaptability to Situations
____
____
_____
_____
_______
Ability to Inspire Others
____
____
_____
_____
_______
Assumes Responsibility
____
____
_____
_____
_______
Administrative Qualities
Organizational Skills
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Written Skills
____
____
_____
_____
_______
Communication Skills
____
____
_____
_____
_______
Time Management Skills
____
____
_____
_____
_______
Computer Skills
____
____
_____
_____
_______
Ability to Plan
____
____
_____
_____
_______
Flexibility with Programs
____
____
_____
_____
_______
Follows Policies/Procedures
Orderly and Clean
____
____
____
____
_____
_____
_____
_____
_______
_______
13
Teaching Qualities
Presentation Skills
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Ability to Teach Activities
____
____
_____
_____
_______
Ability to Demonstrate
Activities
____
____
_____
_____
_______
Social Qualities
Friendly/Courteous
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Enthusiastic
____
____
_____
_____
_______
Gets Along with Others
____
____
_____
_____
_______
Professional Activities
Strives for Self Improvement
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Overall Evaluation of Work
____
____
_____
_____
_______
Please list your strengths in this practicum/independent study experience:
Please list areas in which you could improve:
Please explain what you have learned about the clinical environment or clinical practice of biomedical
engineering:
14
PRACTICUM/INDEPENDENT STUDY MIDTERM EVALUATION FORM
School of Biomedical Engineering
Midterm Evaluation of Student by Practicum/Ind. Study Supervisor
To be completed by the practicum/ind. study supervisor at the midpoint of the semester and
reviewed with the student. Please return to the SBME office, 225 Scott Bioengineering
Building, or 1376 Campus Delivery, Fort Collins, CO 80523-1376.
Please use the accompanying rating scale to assist the student in understanding his/her strengths
and needs for improvement. Thank you for your time.
STUDENT NAME: _____________________________________________________
DATE: ________________________________________________
Rating Scale:
Outstanding…..………………….few other students equal
Good……………….…………….above most other students
Average……………………….….as expected for age and experience
Poor………………………………inferior
N/A……………………………….not applicable
PRACTICUM/IND STUDY SUPERVISOR SIGNATURE:
______________________________________________________________________________
STUDENT SIGNATURE:
______________________________________________________________________________
15
PRACTICUM/INDEPENDENT STUDY MIDTERM EVALUATION FORM
School of Biomedical Engineering
Midterm Evaluation of Student by Practicum Supervisor
Student Name ________________________________________________________________________
Date ________________________________________________________________________________
Technical Knowledge
General Education/
Technical
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
______
Life Sciences
____
____
_____
_____
_______
Engineering
____
____
_____
_____
_______
Leadership Qualities
Initiative
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
______
Confidence
____
____
_____
_____
_______
Resourcefulness
____
____
_____
_____
_______
Originality
____
____
_____
_____
_______
Ability to Analyze Problems
____
____
_____
_____
_______
Adaptability to Situations
____
____
_____
_____
_______
Ability to Inspire Others
____
____
_____
_____
_______
Assumes Responsibility
____
____
_____
_____
_______
Administrative Qualities
Organizational Skills
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Written Skills
____
____
_____
_____
_______
Communication Skills
____
____
_____
_____
_______
Time Management Skills
____
____
_____
_____
_______
Computer Skills
____
____
_____
_____
_______
16
Ability to Plan
____
____
_____
_____
_______
Flexibility with Programs
____
____
_____
_____
_______
Follows Policies/Procedures
____
____
_____
_____
_______
Orderly and Clean
____
____
_____
_____
_______
Teaching Qualities
Presentation Skills
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Ability to Teach Activities
____
____
_____
_____
_______
Ability to Demonstrate
Activities
____
____
_____
_____
_______
Social Qualities
Friendly/Courteous
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Enthusiastic
____
____
_____
_____
_______
Gets Along with Others
____
____
_____
_____
_______
Professional Activities
Strives for Self Improvement
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Overall Evaluation of Work
____
____
_____
_____
_______
Please list the student’s strengths in this practicum/independent study experience:
Please list areas in which the student could improve:
Please explain what the student has learned about the clinical environment or clinical practice of
biomedical engineering:
Other Comments:
17
Colorado State University
School of Biomedical Engineering
Final Evaluation of Student by Practicum Supervisor
To be completed by the practicum supervisor at the end of the semester and reviewed with the
student. Please return to the SBME office, 225 Scott Bioengineering Building, or 1376 Campus
Delivery, Fort Collins, CO 80523-1376 no later than the Friday of finals week.
Please use the accompanying rating scale to assist the student understand his/her strengths and
needs for improvement.
STUDENT NAME: ____________________________________________________________
DATE: _______________________________________________________________________
Rating Scale:
Outstanding…..………………….few other students equal
Good……………….…………….above most other students
Average……………………….….as expected for age and experience
Poor………………………………inferior
N/A……………………………….not applicable
This course is graded as Satisfactory or Unsatisfactory.
This student earned the grade of ___S or ____ U
PRACTICUM SUPERVISOR SIGNATURE:
______________________________________________________________________________
STUDENT SIGNATURE:
______________________________________________________________________________
18
Student Name ________________________________________________________________________
Date ________________________________________________________________________________
Technical Knowledge
General Education/
Technical
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
______
Life Sciences
____
____
_____
_____
_______
Engineering
____
____
_____
_____
_______
Leadership Qualities
Initiative
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
______
Confidence
____
____
_____
_____
_______
Resourcefulness
____
____
_____
_____
_______
Originality
____
____
_____
_____
_______
Ability to Analyze Problems
____
____
_____
_____
_______
Adaptability to Situations
____
____
_____
_____
_______
Ability to Inspire Others
____
____
_____
_____
_______
Assumes Responsibility
____
____
_____
_____
_______
Administrative Qualities
Organizational Skills
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Written Skills
____
____
_____
_____
_______
Communication Skills
____
____
_____
_____
_______
Time Management Skills
____
____
_____
_____
_______
Computer Skills
____
____
_____
_____
_______
Ability to Plan
____
____
_____
_____
_______
Flexibility with Programs
____
____
_____
_____
_______
Follows Policies/Procedures
____
____
_____
_____
_______
Orderly and Clean
____
____
_____
_____
_______
Teaching Qualities
Presentation Skills
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
19
Ability to Teach Activities
____
____
_____
_____
_______
Ability to Demonstrate
Activities
____
____
_____
_____
_______
Social Qualities
Friendly/Courteous
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Enthusiastic
____
____
_____
_____
_______
Gets Along with Others
____
____
_____
_____
_______
Professional Activities
Strives for Self Improvement
N/A
____
Poor
____
Average
_____
Good
_____
Outstanding
_______
Overall Evaluation of Work
____
____
_____
_____
_______
Please list the student’s strengths in this practicum/independent study experience:
Please list areas in which the student could improve:
Please explain what the student has learned about the clinical environment or clinical practice of
biomedical engineering:
Other Comments:
Positions for which you would consider the student qualified upon graduation:
Suggestions to the student:
Suggestions for the Practicum/Independent Study course:
I would consider this student for employment at my facility:
20
Yes
No
Colorado State University
School of Biomedical Engineering
Final Evaluation of Practicum/Independent Study Experience by Student
DATE ______________________________________________________________________________
FACILITY NAME ____________________________________________________________________
STUDENT NAME ____________________________________________________________________
Please elaborate on any of the following questions if you wish
1. Were you satisfied with your practicum/ independent study experience?
Yes
No
Please explain:
2. Were you fully aware of your duties and responsibilities at your practicum/independent study
experience?
Yes
No
3. Were you aware of the functions and purposes of the facility where you worked?
Yes
No
4. Did you feel academically prepared for the practicum/independent study experience?
Yes
No
5. Did you feel that you were making important contributions to the facility?
Yes
No
6. Did you experience any problems as a result of your practicum/independent study experience?
Yes
No
21
7. Did you feel free to discuss problems with your practicum/independent study supervisor?
Yes
No
8. Did you feel that you were treated as a professional?
Yes
No
9. Were you allowed to make decisions on your own?
Yes
No
10. Were you responsible for providing your supervisor with written reports of your activities?
Yes
No
11. How would you rate your performance?
Poor
Average
Excellent
Please review with your practicum/independent study supervisor and sign.
STUDENT SIGNATURE ___________________________________________ DATE _____________
22