Practicum Waiver/Substitution Form

PRACTICUM WAIVER/SUBSTITUTION FORM

JD/MPH

Complete the form and submit to Jessica Pratt .

1. STUDENT INFORMATION

Full Name:Click here to enter text.Student ID #: Click here to enter text.

Anticipated Graduation Date: Click here to enter text.

1. COURSEWORK SUBSTITUTION

Circle the Law School course you will take to replace the practicum and enter the semester you will complete it.

LAW7247/7248 Health Legislation & Advocacy I&II

LAW6090/6091 HeLP Legal Services Clinic I&II

LAW8001/8005/8008 Externship

Semester: Click here to enter text.
Credit hours: Click here to enter text.

1. PRACTICAL EXPERIENCE INFORMATION

Provide a detailed description of activities.Explain how the experience demonstrates application of knowledge from the MPH core and health management and policy concentration competencies. The narrative should include direct reference to MPH Competencies and 10 Essential Services (listed in table below).

Practical Experience Site:

Agency (or externship, course, law clinic) name: Click here to enter text.

Agency address: Click here to enter text.

Dates of Experience: Click here to enter text.

Supervisor/Instructor Contact Information: Click here to enter text.

Practical Experience Description:

The narrative should include direct reference to MPH Competencies and 10 Essential Services (listed in table below).

Click here to enter text.

1. PUBLIC HEALTH LEARNING & SCHOLARSHIP

Describe the degree to which your experience 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 Management & Policy Competencies / 1
None of the Time / 2
Some of the Time / 3
All
of the Time
Demonstrate the skills of effective communication. / ☐ / ☐ / ☐ /
Demonstrate team building, negotiation, and conflict management skills. / ☐ / ☐ / ☐ /
Demonstrate knowledge of strategy development and change management principles. / ☐ / ☐ / ☐ /
Describe the attributes of effective leadership and the skills of effective leadership including decision making, vision setting and mentoring. / ☐ / ☐ / ☐ /
Describe the legal bases for public health services. / ☐ / ☐ / ☐ /
Explain principles of ensuring community health safety including emergency preparedness and response. / ☐ / ☐ / ☐ /
Describe alternative strategies for collaboration and partnership among organizations focused on public health goals. / ☐ / ☐ / ☐ /
Apply commonly used frameworks for policy analysis to prominent, contemporary public health issues. / ☐ / ☐ / ☐ /
Utilize theories of policymaking to develop policy proposals that address public health challenges. / ☐ / ☐ / ☐ /
Demonstrate application of economic principles to analyze and characterize public health and health service policies and issues. / ☐ / ☐ / ☐ /
Identify and discuss the main components of the healthcare system in the United States, the underlying sources of market power, and in the context of interlocking market segments and market power held by different players, how these components will be impacted by current reform proposals. / ☐ / ☐ / ☐ /

1. 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 / 1
None 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 / ☐ / ☐ / ☐ /

1. SIGNATURES

Applications without required signatures will be returned without review.

Student signature:Date:

UPDATED 12/2014