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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