UNIVERSITY OF MASSACHUSETTS
AMHERST
School of Public Health and Health Sciences
Arnold House
715 North Pleasant Street
Amherst, MA 01003-9304
Voice: 413.545.4420
Fax:
413.545.1645
www.umass.edu.sphhs
Site Supervisor Agreement to Advise PHP Practicum
Name of Student: ________________________________________________________________
Email Address of Student: _________________________________________________________
Dates of Practicum: from: _____________________ to: _________________________________
Name of Practicum Site Supervisor: __________________________________________________
Practicum Site Supervisor’s Title: ____________________________________________________
Name of Agency/Organization: ______________________________________________________
Supervisor’s E-mail Address: _________________________________________________
Supervisor’s Phone Numbers: _________________________________________________
By submitting this form, I affirm that I agree to serve as Advisor and Site Supervisor for the Practicum
experience of the student listed above.
I received a copy of the Site Supervisor Responsibility form, have read and reviewed it, understand the
expectations involved, and commit to fulfilling them.
___________________________________________________
Your Typed Name
_________________
Date
Directions for Submission: Please attach this form to an email from your work email address and email
it to the student directly. S/he will upload your email and this attached form on the online course site.
From Dean Alieon, Associate Dean Dan Gerber, Practicum Director Kathryn Tracy, and all of us
affiliated with the MPH program in Public Health Practice thank you for your generosity in serving as
a Site Supervisor. The Practicum is a valuable experience for our students because of you!