internship and special project proposal revised 2.7users.phhp.ufl.edu/prycefegumpss/internship and...
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Directions: PleasecompletetheENTIREapplicationformbeforesubmitting.Incompleteorhandwrittenapplicationswillbeautomaticallyreturnedtothestudentunlesspriorarrangementshavebeenmade.
STUDENTINFORMATION
Name:__________________________________________________________________________________
Concentration:_____________________________________________________________________
UFID:______________________________________
MailingAddressduringInternship:
______________________________________________________________________________________________________________________Street Apt.# City State Zip
Phone#___________________________ Email:_____________________________________________
PermanentAddress ________________________________________________________________________________________
INTERNSHIPINFORMATION
Course:PHC6946_______ CourseCredits:_______________________________________
Semester/YearDesired:_________________ FinalReportDueDate:___PublicHealthDay___________
ProjectTitle:______________________________________________________________________________
Myinternshipislocatedinaruralarea YESNO
Myinternshipimpactsruralpopulations(s) YESNO
Doyouhavereliabletransportation? YESNO
Doyouhaveanydisabilitiesthatmighthinderyourperformanceduringyourproject? YESNO
Ifyes,pleaseexplain
_______________________________________________________________________
Doesthissiterequireaformalcontracttobesignedpriortobeginninginternship? YES NO
Areyourequiredtohaveinsuranceasresultofparticipationinthisproject? YES NO
IfYES,pleasecheckallthatapply:
InternshipandSpecialProjectProposal
UniversityofFloridaMaterofPublicHealthProgram
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PersonalAccidentInsurance PersonalLiabilityInsurance HealthInsurance
Other:
__________________________________________________________________
INTERNSHIPPRECEPTOR/AGENCYINFORMATION
Pleaseincludeacopyofthepreceptor’sresumeorCV
Organization/AgencyName:________________________________________________________________________________
Preceptor’sName,CredentialsandPositionTitle:
____________________________________________________________________________________________________________________________
Address:_________________________________________________________________________________________________________________Street Suite/Room# City State Zip
Phone#:____________________________________________ Fax#:_______________________________________________________
Email:__________________________________________________________________________________
INTERNSHIPANDSPECIALPROJECTWORKPLANAttachadetailedworkplanthatincludestheitemsbelow.Site:InternshipOrganization/Agency—thepurpose,missionorgoalsoftheorganizationandthepopulation(s)theyserve,especiallytheorganization’spublichealthprogramsorprojects.Internship:Theworkplanmustprovidesufficientinformationtodeterminewhethertheinternshipcanbecompletedinthetimeallotted.
Student’sGoalsandObjectives—includelearningobjectivesforallprojectsandactivitiesyouwillbeworkingonduringyourinternship.Identifytheobjectivesforyourinternshipclearly
Competencies—identifythespecificMPHandconcentration‐specificcompetenciesyouwillstrengthenduringyourinternship
Significance—describewhyyourinternshipissignificanttopublichealth Timeline—includeatimelineforcompletionofyourrequiredcontacthours.Ifaparticularassignmentor
activitywillbeongoing,pleaseindicate.Beasspecificaspossible. RoleofParticipatingParties—describetherolesofyourpreceptorandteammates(ifapplicable).
SpecialProject:Theworkplanmustspecifyatleastonespecialprojectandprovidesufficientinformationtodeterminewhethertheprojectcanbecompletedinthetimeallottedtothisinternship.
Student’sGoalsandObjectives—includelearningobjectivesforallprojectsandactivitiesyouwillbeworkingonforyourspecialproject.Outlinethemclearly.
Competencies‐identifythespecificMPHandconcentration‐specificcompetenciesyouwillstrengthenduringyourspecialproject
Significance—describewhyyourspecialprojectissignificanttopublichealth
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Methods—describethemethods(focusgroups,analysisofarchivaldata,policyanalysis,etc.)youwillusetocarryoutyourproject(s).
Timeline—includeatimelineforcompletionofeachprojectoractivity,Ifaparticularassignmentoractivitywillbeongoing,pleaseindicate.Beasspecificaspossible.
RoleofParticipatingParties—describetherolesofyourpreceptorandteammates(ifapplicable).
IRBAPPROVAL
DoesyourprojectrequireIRB YES NO HaveyousubmittedtoIRB? YES NO
Haveyouobtainedapproval? YES NO
Attachacopyofyourapprovalletter.Ifnotyetobtained,pleaseexplainandspecifyyourtimelineforacquiringapproval:
__________________________________________________________________________________________________________________________________
Isanyotherapprovalnecessary? YES NO
Ifyes,pleaseexplain:________________________________________ Obtained? YES NO
InternshipatCurrentPlaceofEmployment
Iunderstandthat________________________________(studentname)willbeconductinganinternshipinthe
______________________________(DepartmentorProgram)at____________________________________(OrganizationName)
whilemaintainingemploymentinthe_____________________________________________(DepartmentorProgram).
Duringthecourseoftheinternship,thestudentwillundertakedutiesandresponsibilitiesthataredifferentfromcurrentdutiesandresponsibilities.Hoursrelatedtocurrentresponsibilitiescannotbecountedtowardinternshiphours;neithercaninternshiphourscountasregularworkhours.
_______________________________________________________________EmployerSignatureandDate
SIGNATURES
Bysigningbelow,theparticipatingpartiesindicatethattheyhavereadandapprovedthestudent’s
Internship/SpecialProjectworkplan/proposal.
_______________________________________________ ____________________________________________StudentSignatureandDate AgencyPreceptorSignatureandDate
________________________________________________ _____________________________________________FacultyAdvisorSignatureandDate UFInternshipCoordinatorSignatureandDate