This form must be submitted to the Practicum Coordinator before the student will be allowed to register. Please complete this form electronically; the text fields will expand as you type. Submit to the Practicum Coordinator, Jessica Howell Pratt, via email () or fax 404-413-1489.

MPH Goals for Practicum
The practicum should provide the student with an opportunity to perform the following skills:
1.  Demonstrate effective written and oral skills for communicating with different audiences in the context of professional public health activities.
2.  Apply evidence-based principles and the scientific knowledge base to critical evaluation and decision-making in public health.
3.  Promote high standards of personal and organizational integrity, compassion, honesty and respect for all people.
4.  Work collaboratively with diverse communities and constituencies (e.g. researchers, practitioners, agencies and organizations) to advance public health goals.

Student Name: Click here to enter text. GSU Email: Click here to enter text.

Panther ID: Click here to enter text. Phone number: Click here to enter text.

MPH Concentration: Click here to enter text.

Anticipated Graduation Term: Click here to enter text.

Preceptor Name: Click here to enter text. (include credentials – MD, MPH, etc.)

Title: Click here to enter text.

Organization (office/department/division, if applicable): Click here to enter text.

Address: Click here to enter text.

Email: Click here to enter text. Phone number: Click here to enter text.

Practicum Title: Click here to enter text.

Proposed Dates: from Click here to enter text. through Click here to enter text.

Location: Click here to enter text.

Practicum Description

Describe the nature and scope of the proposed project: Click here to enter text.

Practicum Goals

In the table below, list your practicum goals, which should be selected from the MPH competencies, found here: http://publichealth.gsu.edu/students/practicum/practicum-application-2/. Select three to five competencies that you will demonstrate in your practicum experience: one from the “core” list, one from your currently declared concentration, and one to three more competencies from any of the above (core or any concentration). Identify the types of activities you plan to undertake, and indicate how you will assess your progress. (Fields will expand as you type.)
Learning Goals / Activities / Assessment
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Practicum Worksite & Resources

Describe the facilities, technologies, materials, or supplies that will be used by you (e.g. work space, access badge, data, processing applications, etc.). Provide the source and amount of funding, if any.
Click here to enter text.

AGREEMENT

I have participated in the development of the practicum proposal and agree to conditions (e.g. learning goals, preceptor) specified above. If it is necessary to change any of the specified conditions, I agree to make the changes known to each of the persons whose signatures appear below.

By signing, I also confirm that this practicum is separate and distinct from my regular duties, if completing at my place of employment.

Student signature: Date: ______

Preceptor signature: ______Date: ______

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