Field Placement - SPH Undergraduate-Level Field Placement Application

GSPH Undergraduate-Level Field Placement Application

PH 497 - Field Placement Overview
Field Placement Planning & Enrollment Steps
Finding an Internship
Request for Field Placement Approval
PH 497 Registration Code Request
Online Evaluation Form Students
Online Evaluation Form Field Supervisors
Questions?

Request for Field Placement Approval

Student - Submit the following form prior to beginning your field practice experience. Please refer to the Internship Contract instructions for more guidance on completing the Course Information section below.

NOTE: You may secure and begin your internship prior to the semester you register for PH 497; however, you will need to have received approval from the Field Placement Advisor (save the email record you receive) and remember to submit the PH 497 Registration Code Request during the registration period.

STUDENT INFORMATION
Last Name:		First Name:
Red ID #:		*Advisor:**
Email:		Confirm Email:
Phone:		Alt. Phone:
Address:	(street address, city, zip)
Concentration:		if other:
SDSU COURSE INFORMATION
Semester:		Year:
Project Description:	Provide a brief description of the project you will be working on. Include project mission, objectives, key project activities and target population and/or community.
Learning Objectives:
Major Tasks/ Responsibilities:
FIELD TRAINING SITE INFORMATION
Site Affiliation:
Supervisor's Name:		Supervisor's Title:
Phone:		Supervisor's Email:
Mailing Address:	(street address, city, zip)
Field Site:	if other:
Type of Business/Site:	if other:
Primary Population business/ site serves:	if other:
Public Health Focus:	(Choose option that best describes the focus area of your field training experience.) if other:
Is there compensation for this field practicum?	Yes No Unsure N/A (I am employed by this field site) If yes, please explain:
Estimated Start Date:	(MM/DD/YYYY)	Estimated Hours per week:
ADDITIONAL INFORMATION
Comments to Field Placement Coordinator/ Faculty Advisor:

* Contents of this form will be sent to the Field Advisor for final approval. Students wishing to register for credit, must also submit the PH 497 Registration Code Request to officially enroll in the class in the semester in which they seek credit. See Field Placement Planning & Enrollment Steps for more information.