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Practicum Forms and Paperwork

Students Forms

Student written assignment and Power Point Poster

Site Supervisor Forms

Affiliation Agreement, Statement of Understanding and Letter of Understanding
One of these three agreements is required for an MPH practicum site. These agreements are legal agreements between the University of Washington School of Public Health and the Site, and outlines expectations as to the conduct of all parties, the resources to be provided and the liability to be assumed. The information provided from the student's MPH Practicum Agreement form will be used by the MPH Practicum Coordinator to initiate one of these agreements with the sites.

These agreements must be initiated prior to students beginning their field-based placement.

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MPH PRACTICUM FINAL CHECKLIST
After the student has registered for the practicum course, the MPH Practicum Final Checklist will be sent by email to the student. Upon practicum completion of the written assignment and Power Point poster, the student will email a copy of their assignment and poster to their faculty advisor and to the MPH practicum coordinator. The student will then submit the checklist along to their faculty advisor. The faculty advisor then assesses the project and annotates on the checklist that the assignment was received and credit was given.

The student will forward the signed checklist to the MPH practicum coordinator. Verifying that the written assignment and poster have been received, the MPH practicum coordinator will sign the checklist and forward it to the department so the grade if credit can be recorded.

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MPH Practicum Prerequisites Form or MPH Practicum Prerequisites Form for PCMI students
MPH students are required to complete a MPH Practicum Prerequisites Form during their first quarter in the program and return the completed form to their department Program Student Coordinator. The Program Student Coordinator will verify that immunization and background check requirements have been met. A copy of the completed form is sent from the Program Student Coordinator to the student's Faculty Advisor and the MPH Practicum Coordinator.

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MPH Practicum Learning Contract (formally Practicum Agreement)
This form serves as a proposal for the project and outlines work to be undertaken during the field placement. The student works with the Site Supervisor and with a Faculty Advisor in developing the MPH Practicum Agreement.

The MPH Practicum Learning Contract must be completed and returned to the MPH Practicum Coordinator BEFORE beginning the field placement.

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Student Agreement for Practicum Placement in a Foreign Country
For students who intend to conduct a practicum in a foreign country, a Student Agreement for Practicum Placement in a Foreign Country is required and must be on file before the student begins their field placement. Upon receipt of the student's completed MPH Practicum Learning Contract, the MPH Practicum Coordinator will generate the student agreement. This form must be signed by the student and the student's faculty advisor. The completed form will be kept on file in the MPH Practicum Office.

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Waiver and Substitution Forms

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Washington State Background Check, Self Disclosure and Immunization Requirements
To comply with Washington State law regarding the Child/Adult Abuse Information Act, all students must complete a Washington State Patrol Criminal History Background Check and a criminal self-disclosure form for the MPH practicum.

All students in Health Sciences must meet immunization requirements developed by the University of Washington Health Sciences Center. Students must ensure that the immunizations and skin tests are current during the first quarter of enrollment in the MPH program as well as prior to the practicum placement. Program student coordinators must have a student’s complete, up-to-date immunization information on file before the student will be allowed to participate in the practicum.

**Turn this form in to your department Program Student Coordinator, along with immunization verification and MPH Practicum Prerequisites form during your first quarter in the program.

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Please direct all questions regarding the practicum program to:

Rene' M. Lucas, MPH Practicum Coordinator
Dean's Office
School of Public Health
Box 357230
University of Washington
Seattle, WA 98195-7230
(206) 685-8904