Procedures for Executing Agreements Related to MPH Practicum

Procedure for Executing Affiliation Agreement with an Organization Outside UofL

Important Note: Exhibit 1 of the Affiliation Agreement, titled “Student Practice Site Agreement,” is NOT to be filled in or signed by anyone. It is a required exhibit of the Affiliation Agreement that indicates the form of the agreement a student and the University will sign separately (see below).

  1. Site is given two documents:
  2. Information for the Prospective Practice Site
  3. Affiliation Agreement (template)
  4. One of the following:
  5. Site discusses agreement with Associate Dean regarding changes or clarifications.
  6. Site and University agree to terms and conditions.
  7. Associate Dean collects information needed to prepare documents.
  8. Site accepts Agreement template without change.
  9. Student or MPH Program Coordinator collects the following information:
  10. Legal name of site (usually ending in “Inc.” or LLC”).
  11. Name and address of site contact person for contractual matters.
  12. Name and title of site person signing agreement.
  13. Above information is delivered to Associate Dean.
  14. Associate Dean prepares four (4) stapled copies of Affiliation Agreement for signature.
  15. Associate Dean obtains following signatures on each copy:
  16. Dean
  17. MPH Program Director
  18. Privacy Officer
  19. AssociateUniversity Counsel
  20. Associate Dean delivers to MPH Program Coordinator four (4) partially executed copies marked where site representative is to sign.
  21. MPH Program Coordinator delivers to the site representative the four (4) partially signed copies by:
  22. Having a student take them to the siterepresentative,
  23. Taking them to the site representative himself or herself,
  24. Postal, delivery, or courier service, or
  25. Some other reliable method or arrangement.
  26. Site representative signs the four (4) copies.
  27. Site retains one (1) of the signed copies for its records.
  28. Site representative returns three (3) of the signed copies by:
  29. Having a student take them to the School,
  30. Taking them to the School himself or herself,
  31. Postal, delivery, or courier service, or
  32. Some other reliable method or arrangement.
  33. Three (3) signed copies are delivered to Associate Dean.
  34. Associate Dean distributes the three (3) signed copies as follows:
  35. One (1) to Privacy Officer.
  36. One (1) to Assistant Director of Administration.
  37. One (1) to MPH Program Coordinator.

Note: The sequence of steps after Step 3 in this procedure may be varied as long as the documents are executed and distributed as intended.

Procedure for Executing Student Practice Site Agreement at Practice Site Outside UofL

Important Note: A Student Practice Site Agreement can be executed only if an Affiliation Agreement is currently in force between the Practice Site and the University or such Agreement is being executed contemporaneously.

  1. MPH Program Coordinator makes and gives to Student a copy of the Affiliation Agreement with the Practice Site (available at
  2. Student makes four (4) STAPLED copies of template for Student Practice Site Agreement at External Site (available at
  3. Student PRINTS the following on page 1 of each copy of Student Agreement (in appropriate blanks):
  4. Today’s date with format the same as “January 1, 2006”.
  5. Student’s name as used in formal documents.
  6. Name of Practice Site as given on page 1 of Affiliation Agreement.
  7. Student signs on page 3 of each copy of Student Agreement.
  8. Student delivers to MPH Program Coordinator the four (4) partially executed copies of Student Agreement.
  9. MPH Program Coordinator obtains signature of MPH Program Director on each copy of Student Agreement.
  10. MPH Program Coordinator delivers to Associate Dean the four (4) partially executed copies of Student Agreement.
  11. Associate Dean either signs on behalf of or obtains signature of Dean on each copy of Student Agreement.
  12. Associate Dean distributes the four (4) executed copies of Student Agreement as follows:
  13. One (1) copy to Assistant Director of Administration.
  14. One (1) copy to Student Services for Student’s file.
  15. Two (2) copies to MPH Program Coordinator.
  16. MPH Program Coordinator retains one (1) copy for Program’s records.
  17. MPH Program Coordinator delivers one (1) copy to Student for his or her records.
  18. Student makes copy of his or her copy and delivers it to Practice Site.

Procedure for Executing Practice Site Agreement with an Organization Inside U of L

Important Note: Exhibit 1 of the Practice Site Agreement, titled “Student Practice Site Agreement,” is NOT to be filled in or signed by anyone. It is a required exhibit of the Practice Site Agreement that indicates the form of the agreement a student and the University will sign separately (see below).

  1. Site is given two documents:
  1. Information for the Prospective Practice Site
  2. Practice Site Agreement (template)
  1. One of the following:
  1. Site discusses agreement with Associate Dean regarding changes or clarifications.
  2. Site and School agree to terms and conditions.
  3. Associate Dean collects information needed to prepare documents.
  4. Site accepts Agreement template without change.
  1. Student or MPH Program Coordinator collects the following information:
  2. Official name of site.
  3. Name and address of site contact person for contractual matters.
  4. Name and title of site person signing agreement.
  5. Above information is delivered to Associate Dean.
  1. Associate Dean prepares four (4) stapled copies of Practice Site Agreement for signature.
  2. Associate Dean obtains following signatures on each copy:
  1. Dean
  2. MPH Program Director
  1. Associate Dean delivers to MPH Program Coordinator four (4) partially executed copies marked where site representative is to sign.
  2. MPH Program Coordinator delivers to the site representative the four (4) partially signed copies by:
  1. Having a student take them to the siterepresentative,
  2. Taking them to the site representative himself or herself,
  3. Postal, delivery, or courier service, or
  4. Some other reliable method or arrangement.
  1. Site representative signs the four (4) copies.
  2. Site retains one (1) of the signed copies for its records.
  3. Site representative returns three (3) of the signed copies by:
  1. Having a student take them to the School,
  2. Taking them to the School himself or herself,
  3. Postal, delivery, or courier service, or
  4. Some other reliable method or arrangement.
  1. Three (3) signed copies are delivered to Associate Dean.
  2. Associate Dean distributes the three (3) signed copies as follows:
  1. One (1) to Assistant Director of Administration.
  2. Two (2) to MPH Program Coordinator for Program’s records.

Note: The sequence of steps after Step 3 in this procedure may be varied as long as the documents are executed and distributed as intended.

Procedure for Executing Student Practice Site Agreement at Practice Site Inside UofL

Important Note: A Student Practice Site Agreement can be executed only if an Practice Site Agreement is currently in force between the Practice Site and the School or such Agreement is being executed contemporaneously.

  1. MPH Program Coordinator makes and gives to Student a copy of the Practice Site Agreement with the Practice Site (available at
  2. Student makes four (4) STAPLED copies of template for Student Practice Site Agreement at Internal Site (available at
  3. Student PRINTS the following on page 1 of each copy of Student Agreement (in appropriate blanks):
  4. Today’s date with format the same as “January 1, 2006”.
  5. Student’s name as used in formal documents.
  6. Name of Practice Site as given on page 1 of Practice Site Agreement.
  7. Student signs on page 3 of each copy of Student Agreement.
  8. Student delivers to MPH Program Coordinator the four (4) partially executed copies of Student Agreement.
  9. MPH Program Coordinator obtains signature of MPH Program Director on each copy of Student Agreement.
  10. MPH Program Coordinator delivers to Associate Dean the four (4) partially executed copies of Student Agreement.
  11. Associate Dean either signs on behalf of or obtains signature of Dean on each copy of Student Agreement.
  12. Associate Dean distributes the four (4) executed copies of Student Agreement as follows:
  1. One (1) copy to Assistant Director of Administration.
  2. One (1) copy to Student Services for Student’s file.
  3. Two (2) copies to MPH Program Coordinator.
  1. MPH Program Coordinator retains one (1) copy for Program’s records.
  2. MPH Program Coordinator delivers one (1) copy to Student for his or her records.
  3. Student makes copy of his or her copy and delivers it to Practice Site.

Persons Currently in Positions Cited in Procedures

Position / Person
Dean / Richard D. Clover, MD
Associate Dean / Peter L. Walton, MD
MPH Program Director / Robert R. Jacobs, PhD
MPH Program Coordinator / LaTonia Peters, MPH
Assistant Director of Administration / Peggy Beachy
AssociateUniversity Counsel / Glenn Bossmeyer
Privacy Officer / Marti Arvin

Version 2Page 109/12/06