Scott Bioengineering Building
225 Engineering Success Center
Fort Collins, CO 80523-1376
970/491-7077
http://www.engr.colostate.edu/sbme/
Student Agreement
The importance of this practicum packet cannot be emphasized enough. Please read all parts of the packet prior to beginning your clinical practicum experience. Portions of this packet must be returned to your adviser in the School of Biomedical Engineering, Engineering Success Center, Scott Bioengineering Building, at different times during the practicum experience. There is NO grace period or acceptable reason for not fulfilling your responsibility in this matter. This course is graded on a pass/fail system and failure to submit assignments in a timely manner will adversely affect your grade. Failure to submit all assignments will result in a failing grade.
This packet is due as soon as possible and at least two weeks prior to the start of the semester for which you would like credit.
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 Becca Kronenbitter
Advisor, BME Dual Degree students Advisor, BME Minor students
School of Biomedical Engineering School of Biomedical Engineering
970-491-7077 970-491-2557
*I have read the above statement and agree to all terms as stated.
Student Signature ______
Student ID # ______
Date ______
Rev 4-2015
School of Biomedical Engineering
Health Insurance Notification
Depending on the type of practicum 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 ______
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.
Student Interest Form (if applicable) Date submitted: ______
Student Intake Form Date submitted: ______
Health Insurance Notification Form Date submitted: ______
Tentative Work Schedule Date submitted: ______
Practicum Bi-Weekly Reports Date submitted: ______
Practicum Midterm Student Date submitted: ______
Self-Evaluation Form
Midterm Evaluation of Student Date submitted: ______
By Practicum Supervisor
Final Evaluation of Student by Date submitted: ______
Practicum Supervisor
Final Evaluation of Practicum Date submitted: ______
Experience by Student
Final Presentation Date presented: ______
Biomedical Engineering
Internship/Practicum Interest Form
Turn into the SBME Office at start of term for which you the practicum occurs.
Date ______/______/______
Full Name______
CSU ID ______- ______- ______Email Address ______
Local Phone # (_____) ______- ______Cell # (______) ______- ______
Local Address ______
City ______State ______Zip ______
Expected Graduate Date: Fall ______Spring ______Summer ______
___ Biomedical Engineering Dual Degree student with ____ CBE ____ EE ___ MECH
___ Biomedical Engineering Minor student with ______Engineering Major of ______
_____Non Engineering Major of ______
___ Graduate Student: ____MS Student ____ ME Student ______PhD Student
Intended Semester for Internship/Practiucm: Fall ______Spring ______Summer ______
Please list your preferences 1 to 4:
______Within Ft. Collins Area ______Front Range Area
______Within Colorado ______Outside of Colorado
Area of Biomedical Engineering Interest (check all that apply):
Academic research
Working in industry
Biomechanics and biomaterials
Molecular, cellular and tissue Engineering
Medical diagnostics, devices and imaging
Other (explain): ______
______
______
Please turn in electronic resume with all internship/practicum intake forms
Date received ______/ ______/ ______GPA ______
Please submit a brief few paragraphs on your desires and goals for your internship experience.
Internship/Practicum Intake Form
Complete the information and return to the School of Biomedical Engineering (225, Scott Bioengineering) BEFORE you accept an offer for an internship or practicum.
Date: ______
Name: ______
CSU Student ID: ______
Academic Term in which you are registered (semester and year) ______
Email: ______
Home/cell phone number: ______
Major: ______
Number of credits requested __1 __2 __3 __4 __5 __6
(NOTE: 3 – 4 hours/week are required per credit for a 15-week semester. Thus, 1 cr = 45 – 60 hours; 2 cr = 90 – 12 hours; 3 cr = 135 – 180 hours, etc…) The time per week will need to be adjusted for any summer courses; overall hours will be the same, though more per week may be required.
Internship/Practicum Site Information
Internship 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: ______
Please complete this information and return to the School of Biomedical Engineering for practicum/internship approval before accepting a practicum/internship offer.
1) Explain in writingwhat you will be doing in detail.
2) Explain in writing how it relates to biology or medicine.
3) Explain in writing how it relates to engineering.
4) State in writing your learning objectives (which need to be measurable and specific).
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 letter of evaluation stating what you did and how well you met the learning objectives.
Student Responsibilities and Expectations
Please list student’s responsibilities and expectations of practicum experience (to be completed by the Practicum Supervisor and student).
Give copy to Practicum Supervisor, copy to the SBME Office, and keep a copy for your records.
STUDENT SIGNATURE ______
SIGNATURE OF ______
PRACTICUM SUPERVISOR
TENTATIVE WORK SCHEDULE
Complete and give copy to Practicum Supervisor, copy to the SBME Office, and keep copy for your records.
STUDENT NAME: ______
MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / SATURDAY8:00
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
PRACTICUM STUDENT’S 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 syllabus. The reports should be reviewed and signed by your clinical practicum experience supervisor. You are encouraged to discuss any experiences and problems with your practicum advisor 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 ______
PRACTICUM SUPERVISOR (Please write any comments you have on the other side of this form.)
TOTAL HOURS FOR THE WEEK ______
SHORT DESCRIPTION OF PRACTICUM ACTIVITIES
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
WEEKEND
Supervisor Comments:
PRACTICUM 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 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) BIOM495 (1- 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: ______
PRACTICUM MIDTERM EVALUATION FORM
School of Biomedical Engineering
Student Self-Evaluation
STUDENT NAME ______
DATE ______
Technical Knowledge N/A Poor Average Good Outstanding
General Education/ ______
Technical
Life Sciences ______
Engineering ______
Leadership Qualities N/A Poor Average Good Outstanding
Initiative ______
Confidence ______
Resourcefulness ______
Originality ______
Ability to Analyze Problems ______
Adaptability to Situations ______
Ability to Inspire Others ______
Assumes Responsibility ______
Administrative Qualities N/A Poor Average Good Outstanding
Organizational Skills ______
Written Skills ______
Communication Skills ______
Time Management Skills ______
Computer Skills ______
Ability to Plan ______
Flexibility with Programs ______
Follows Policies/Procedures ______
Orderly and Clean ______
Teaching Qualities N/A Poor Average Good Outstanding
Presentation Skills ______
Ability to Teach Activities ______
Ability to Demonstrate ______
Activities
Social Qualities N/A Poor Average Good Outstanding
Friendly/Courteous ______
Enthusiastic ______
Gets Along with Others ______
Professional Activities N/A Poor Average Good Outstanding
Strives for Self Improvement ______
Overall Evaluation of Work ______
Please list your strengths in this practicum 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:
______
______
______
______
______
______
PRACTICUM MIDTERM EVALUATION FORM
School of Biomedical Engineering
Midterm Evaluation of Student by Practicum Supervisor
To be completed by the practicum 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 SUPERVISOR SIGNATURE: ______
STUDENT SIGNATURE: ______
Student Name ______
Date ______
Technical Knowledge N/A Poor Average Good Outstanding
General Education/ ______
Technical
Life Sciences ______
Engineering ______
Leadership Qualities N/A Poor Average Good Outstanding
Initiative ______
Confidence ______
Resourcefulness ______
Originality ______
Ability to Analyze Problems ______
Adaptability to Situations ______
Ability to Inspire Others ______
Assumes Responsibility ______
Administrative Qualities N/A Poor Average Good Outstanding
Organizational Skills ______
Written Skills ______
Communication Skills ______
Time Management Skills ______
Computer Skills ______
Ability to Plan ______
Flexibility with Programs ______
Follows Policies/Procedures ______
Orderly and Clean ______
Teaching Qualities N/A Poor Average Good Outstanding
Presentation Skills ______
Ability to Teach Activities ______
Ability to Demonstrate ______
Activities
Social Qualities N/A Poor Average Good Outstanding
Friendly/Courteous ______
Enthusiastic ______
Gets Along with Others ______
Professional Activities N/A Poor Average Good Outstanding
Strives for Self Improvement ______
Overall Evaluation of Work ______
Please list the student’s strengths in this practicum 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:
______
______
______
______
______
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.
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
PRACTICUM SUPERVISOR SIGNATURE: ______
STUDENT SIGNATURE: ______
Student Name ______
Date ______
Technical Knowledge N/A Poor Average Good Outstanding
General Education/ ______
Technical
Life Sciences ______
Engineering ______
Leadership Qualities N/A Poor Average Good Outstanding
Initiative ______
Confidence ______
Resourcefulness ______
Originality ______
Ability to Analyze Problems ______
Adaptability to Situations ______
Ability to Inspire Others ______
Assumes Responsibility ______
Administrative Qualities N/A Poor Average Good Outstanding
Organizational Skills ______
Written Skills ______
Communication Skills ______
Time Management Skills ______
Computer Skills ______
Ability to Plan ______
Flexibility with Programs ______
Follows Policies/Procedures ______
Orderly and Clean ______
Teaching Qualities N/A Poor Average Good Outstanding
Presentation Skills ______
Ability to Teach Activities ______
Ability to Demonstrate ______
Activities
Social Qualities N/A Poor Average Good Outstanding
Friendly/Courteous ______
Enthusiastic ______
Gets Along with Others ______
Professional Activities N/A Poor Average Good Outstanding
Strives for Self Improvement ______
Overall Evaluation of Work ______
Please list the student’s strengths in this practicum 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:
______
______
______
______
______
______
______