PRACTICUM WAIVER APPLICATION FORM
HEALTH PROMOTION & BEHAVIOR
Complete the form and submit a current CV/resume with the application.
- STUDENT INFORMATION
Full Name:Click here to enter text.Student ID #: Click here to enter text.
Specialty Track or Concentration: Click here to enter text.
Anticipated Graduation Date: Click here to enter text.
- EMPLOYMENT INFORMATION
For each place of public-health related employment, provide a detailed job description/discussion of responsibilities and level of responsibility. Explain how the experience demonstrates application of knowledge from the core and specialty track or concentration. The narrative should include direct reference to MPH Competencies and 10 Essential Services (listed in table below).
Position 1:
Agency name: Click here to enter text.
Agency address: Click here to enter text.
Dates of Employment: Click here to enter text.
Full-time ☐Part-time ☐
Supervisor Contact Information: Click here to enter text.
Contact my supervisor: Yes ☐ No ☐
Position Description:
The narrative should include direct reference to MPH Competencies and 10 Essential Services (listed in table below).
Click here to enter text.Position 2:
Agency name: Click here to enter text.
Agency address: Click here to enter text.
Dates of Employment: Click here to enter text.
Full-time ☐Part-time ☐
Supervisor Contact Information: Click here to enter text.
Contact my supervisor: Yes ☐ No ☐
Position Description:
The narrative should include direct reference to MPH Competencies and 10 Essential Services (listed in table below).
Click here to enter text.Position 3:
Agency name: Click here to enter text.
Agency address: Click here to enter text.
Dates of Employment: Click here to enter text.
Full-time ☐Part-time ☐
Supervisor Contact Information: Click here to enter text.
Contact my supervisor: Yes ☐ No ☐
Position Description:
The narrative should include direct reference to MPH Competencies and 10 Essential Services (listed in table below).
Click here to enter text.- PUBLIC HEALTH LEARNING & SCHOLARSHIP
Describe the degree to which your employment allows you to demonstrate your knowledge and skills in your specific concentration area of learning and scholarship, as described by the Council on Education for Public Health(CEPH) which accredits the School of Public Health.
Health Promotion & Behavior Competencies / 1None of the Time / 2
Some of the Time / 3
All
of the Time
Identify basic theories, concepts and models from a range of social and behavioral disciplines that are used in public health research and practice. / ☐ / ☐ / ☐ /
Describe steps and procedures for the planning, implementation and evaluation of public health programs, policies and interventions. / ☐ / ☐ / ☐ /
Apply theory and strategy-based communication principles across different settings and audiences. / ☐ / ☐ / ☐ /
Apply evidence-based principles and the scientific knowledge base to critical evaluation and decision making in public health. / ☐ / ☐ / ☐ /
Describe the tasks necessary to assure that program implementation occurs as intended. / ☐ / ☐ / ☐ /
Explain how the findings of a program evaluation can be used. / ☐ / ☐ / ☐ /
Explain the contribution of logic models in program development, implementation, and evaluation. / ☐ / ☐ / ☐ /
Differentiate among goals, measurable objectives, related activities, and expected outcomes for a public health program. / ☐ / ☐ / ☐ /
Differentiate the purposes of formative, process, and outcome evaluation. / ☐ / ☐ / ☐ /
Differentiate between qualitative and quantitative evaluation methods in relation to their strengths, limitations, and appropriate uses, and emphases on reliability and validity. / ☐ / ☐ / ☐ /
In collaboration with others, prioritize individual, organizational, and community concerns and resources for public health programs. / ☐ / ☐ / ☐ /
Assess evaluation reports in relation to their quality, utility, and impact on public health. / ☐ / ☐ / ☐ /
- TEN ESSENTIAL PUBLIC HEALTH SERVICES
Document the degree to which you perform one or more of the Ten Essential Public Health Services
Ten Essential Public Health Services / 1None of the Time / 2
Some of the Time / 3
All
of the Time
I / Monitor health status to identify community health problems / ☐ / ☐ / ☐ /
II / Diagnose and investigate health problems and health hazards in the community / ☐ / ☐ / ☐ /
III / Inform, educate, and empower people about health issues / ☐ / ☐ / ☐ /
IV / Mobilize community partnerships to identify and solve health problems / ☐ / ☐ / ☐ /
V / Develop policies and plans that support individual and community health efforts / ☐ / ☐ / ☐ /
VI / Enforce laws and regulations that protect health and ensure safety / ☐ / ☐ / ☐ /
VII / Link people to needed personal health services and assure the provision of health care when otherwise unavailable / ☐ / ☐ / ☐ /
VIII / Assure a competent public health and personal health care workforce / ☐ / ☐ / ☐ /
IX / Evaluate effectiveness, accessibility, and quality of personal and population-based health services / ☐ / ☐ / ☐ /
X / Research for new insights and innovative solutions to health problems / ☐ / ☐ / ☐ /
- COURSEWORK SUBSITUTION
List the course you will take to replace the practicum hours and the semester you will complete it.
Click here to enter text.
- SIGNATURES
Applications without required signatures will be returned without review.
Student signature:Date:
UPDATED 9/2014