SURVEY OF AGENCIES FOR STUDENT FIELD EXPERIENCE

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University of Michigan, School of Public Health
Department of Health Behavior and Health Education

Name(s) of Agency/Program *

Agency/Program Address *

Major health education-related responsibilities of agency/program: *

Supervisor’s Name *

Title or Position *

Email *

Telephone *

Number of years with agency/program *

Number of years in above position *

Would your agency be willing to accept a student intern for a field placement? *

YES, only 1 student

YES, more than 1 student

Have you (or the assigned staff person for the internship) been a field supervisor for any students in the past? *

Yes

Would you be willing to develop a plan of objectives (e.g., explicit statement of mutual expectations and responsibilities) with the student(s) at the beginning of the internship? *

Yes

Are agency staff available to meet regularly with the student to provide supervision and review the plan of objectives? *

Yes

Preference: *

4 months – full-time (May-August)

2 months – full-time (May-June)

2 months – full-time (July-August)

4-8 months – part-time (concurrent with academic courses)

Other:

Required

Type of experiences/skills, which could be provided (check all that apply): *

staff development/training

research or evaluation

program planning

consultation

grant writing

media & materials development

group facilitating

patient health counseling

community organizing

Other:

Required

Stipend/salary available? *

Yes

Will explore

Reimbursement for travel? *

Yes

Will explore

Is private transportation (car) needed? *

Yes

Sometimes; will discuss

What major programs or activities do you anticipate will be available for student experience? Or what major tasks could the student expect? *

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