The Importance of This Practicum Packet Cannot Be Emphasized Enough
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225 Scott Bioengineering Building Fort Collins, CO 80523-1376 970/491-7077 http://www.engr.colostate.edu/sbme
Student Agreement
The importance of this practicum packet cannot be emphasized enough. Please read all parts of the packet prior to beginning your clinical practicum experience. Portions of this packet must be returned to your adviser in the School of Biomedical Engineering, Engineering Success Center, Scott Bioengineering Building, at different times during the practicum/independent study experience. There is NO grace period or acceptable reason for not fulfilling your responsibility in this matter. This course is graded on a pass/fail system and failure to submit assignments in a timely manner will adversely affect your grade. Failure to submit all assignments will result in a failing grade.
This packet is due as soon as possible and at least two weeks prior to the start of the semester for which you would like credit.
If we may be of assistance at any time, please do not hesitate to contact us. We want this experience to be a very personally rewarding one for you.
Brett Eppich Beal Debra Misuraca Advisor, BME major students Advisor, BME Major and Minor students School of Biomedical Engineering School of Biomedical Engineering [email protected] [email protected] 970-491-7077 970-491-2557
*I have read the above statement and agree to all terms as stated.
Student Signature ______
Student ID # ______
Date ______Rev 8/2015
School of Biomedical Engineering Health Insurance Notification
Depending on the type of practicum you are in (paid vs. unpaid), you may not be covered by Workers Compensation in the event you are injured.
○ If you are working at and being paid by a private company (other than CSU), the company is responsible through the Workers Compensation program to provide medical care to you in the event you are injured.
○ If you are working at and being paid by CSU, CSU is responsible through the Workers Compensation program to provide medical care to you in the event you are injured.
○ If you are not being paid while working at a private company (other than CSU), and you are enrolled in CSU credit, you will be covered under the CSU Workers Compensation program.
○ If you are not being paid and are working at CSU, you are responsible for your expenses if injured. It is highly recommended that you have your own medical insurance to cover any injury that may occur on the job.
If you should cause injury to someone else during your practicum experience, you are covered by the University for liability since you are a CSU student. However, liability insurance does not cover you if you are injured.
I have read this form and understand the terms of being involved in the practicum course. I am aware that I may need to be covered under my own medical insurance in the event of injury.
Signature of Student ______
Date ______
2 Internship/Practicum/Independent Study Interest Form Turn into the SBME Office at start of term for which you the practicum occurs.
Date ______/______/______
Full Name______
CSU ID ______- ______- ______Email Address ______
Local Phone # (_____) ______- ______Cell # (______) ______- ______
Local Address ______
City ______State ______Zip ______
Expected Graduate Date: Fall ______Spring ______Summer ______
___ Biomedical Engineering Bachelor’s Degree student with ____ CBE ____ EE ___ MECH ___ Biomedical Engineering Minor student with ______Engineering Major of ______Non Engineering Major of ______
___ Graduate Student: ____MS Student ____ ME Student ______PhD Student
Intended Semester for Internship/Practiucm: Fall ______Spring ______Summer ______
Area of Biomedical Engineering Interest (check all that apply): Academic research Working in industry Biomechanics and biomaterials Molecular, cellular and tissue Engineering Medical diagnostics, devices and imaging Other (explain): ______
______
______
Please turn in resume with all internship/practicum intake forms Date received ______/ ______/ ______GPA ______
Please submit a brief few paragraphs on your desires and goals for your internship experience.
3 Internship/Practicum/Independent Study Intake Form Complete the information and return to the School of Biomedical Engineering (225, Scott Bioengineering) BEFORE you accept an offer for this credit-bear5ing internship/ practicum. Date: ______Name: ______
CSU Student ID: ______
Academic Term in which you are registered (semester and year) ______
Email: ______
Home/cell phone number: ______
Major: ______
Number of credits requested __1 __2 __3 __4 (NOTE: 3 – 4 hours/week are required per credit for a 15-week semester. Thus, 1 cr = 45 – 60 hours/semester; 2 cr = 90 – 12 hours/semester; 3 cr = 135 – 180 hours/semester, etc…) The time per week will need to be adjusted for any summer courses; overall hours will be the same, though more per week may be required.
Internship/Practicum Site Information Internship Payment Status (paid/unpaid): ______
Pay rate: ______
Student job title: ______
Number of hours worked per week: ______
Start Date: ______Termination Date: ______
Company Information
Company/Agency Name: ______
Address: ______
City: ______State _____ ZIP______
Supervisor Name and title: ______
Phone number: ______FAX: ______
Company website: ______
4 Internship/Practicum/Independent Study Scope of Work
Please complete this information and return to the School of Biomedical Engineering for practicum/internship approval before accepting a practicum/internship/independent study offer.
1) Explain in writing what you will be doing in detail.
2) Explain in writing how it relates to biology or medicine.
3) Explain in writing how it relates to engineering.
4) State in writing your learning objectives (which need to be measurable and specific).
5) Agree to produce a final written report that addresses at least how well you met your learning objectives and supports conclusions you make in this area with data.
6) Get your mentor (practicum supervisor) to agree to write a letter of evaluation stating what you did and how well you met the learning objectives.
5 Student Responsibilities and Expectations
Please list student’s responsibilities and expectations of practicum experience (to be completed by the Practicum Supervisor and student).
Give copy to Internship/Practicum/Independent Study Supervisor, copy to the SBME Office, and keep a copy for your records.
STUDENT SIGNATURE ______
SIGNATURE OF ______PRACTICUM SUPERVISOR
6 Checklist of Forms Turned In This is to help you keep track of forms and paperwork you’ve submitted. You do not turn this into the SBME Office.
Student Interest Form (if applicable) Date submitted: ______
Student Intake Form Date submitted: ______
Health Insurance Notification Form Date submitted: ______
Tentative Work Schedule Date submitted: ______
Practicum Bi-Weekly Reports Date submitted: ______
Practicum Midterm Student Date submitted: ______Self-Evaluation Form
Midterm Evaluation of Student Date submitted: ______By Practicum Supervisor
Final Evaluation of Student by Date submitted: ______Practicum Supervisor
Final Evaluation of Practicum Date submitted: ______Experience by Student
Final Presentation Date presented: ______
7 TENTATIVE WORK SCHEDULE Complete and give copy to practicum/internship/independent study Supervisor, copy to the SBME Office, and keep copy for your records.
STUDENT NAME: ______
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
8:00
9:00
1 10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
8 PRACTICUM STUDENT’S WEEKLY REPORT
To be completed by the student at the end of each week. These reports are due bi-weekly to the SMBE office on the dates listed in your syllabus. The reports should be reviewed and signed by your practicum/internship/independent study supervisor. You are encouraged to discuss any experiences and problems with your supervisor and/or academic advisor and incorporate any suggestions offered. You are welcome to make copies of this report to assist you with your written reports.
DATES OF REPORT ______TO ______
STUDENT NAME ______
SIGNATURE OF SUPERVISOR ______
TOTAL HOURS FOR THE WEEK ______
SHORT DESCRIPTION OF PRACTICUM ACTIVITIES
MONDAY
TUESDAY
WEDNESDAY
9 THURSDAY
FRIDAY
WEEKEND
Supervisor Comments:
10 PRACTICUM/INTERNSHIP/INDEP STUDY MIDTERM EVALUATION FORM School of Biomedical Engineering Student Self-Evaluation
This MUST be completed and turned into the SBME Office at the midpoint of the term.
Instructions: To be completed by the student. Please return to the SBME office before review with practicum supervisor.
Please use the rating scale listed below to evaluate yourself in the areas indicated on the attached sheet.
Circle Course Number: BIOM 476A (2 cr) BIOM 476B (4 cr) BIOM495 (1- 4 cr)
STUDENT NAME: ______
Rating Scale:
Outstanding…………………few other students equal
Good………………………..above most other students
Average……………………..as expected for age and experience
Poor…………………………inferior
N/A………………………….not applicable
STUDENT SIGNATURE: ______
11 PRACTICUM MIDTERM EVALUATION FORM School of Biomedical Engineering Student Self-Evaluation
STUDENT NAME ______
DATE ______
Technical Knowledge N/A Poor Average Good Outstanding General Education/ ______Technical
Life Sciences ______
Engineering ______
Leadership Qualities N/A Poor Average Good Outstanding Initiative ______
Confidence ______
Resourcefulness ______
Originality ______
Ability to Analyze Problems ______
Adaptability to Situations ______
Ability to Inspire Others ______
Assumes Responsibility ______
Administrative Qualities N/A Poor Average Good Outstanding Organizational Skills ______
Written Skills ______
Communication Skills ______
Time Management Skills ______
Computer Skills ______
Ability to Plan ______
Flexibility with Programs ______
Follows Policies/Procedures ______Orderly and Clean ______
12 Teaching Qualities N/A Poor Average Good Outstanding Presentation Skills ______
Ability to Teach Activities ______
Ability to Demonstrate ______Activities
Social Qualities N/A Poor Average Good Outstanding Friendly/Courteous ______
Enthusiastic ______
Gets Along with Others ______
Professional Activities N/A Poor Average Good Outstanding Strives for Self Improvement ______
Overall Evaluation of Work ______
Please list your strengths in this practicum experience:
Please list areas in which you could improve:
Please explain what you have learned about the clinical environment or clinical practice of biomedical engineering:
13 PRACTICUM/INTERNSHIP/INDEP STUDY MIDTERM EVALUATION FORM School of Biomedical Engineering
Midterm Evaluation of Student by Practicum Supervisor
To be completed by the practicum supervisor at the midpoint of the semester and reviewed with the student. Please return to the SBME office, 225 Scott Bioengineering Building, or 1376 Campus Delivery, Fort Collins, CO 80523-1376.
Please use the accompanying rating scale to assist the student in understanding his/her strengths and needs for improvement. Thank you for your time.
STUDENT NAME: ______
DATE: ______
Rating Scale:
Outstanding…..………………….few other students equal
Good……………….…………….above most other students
Average……………………….….as expected for age and experience
Poor………………………………inferior
N/A……………………………….not applicable
PRACTICUM SUPERVISOR SIGNATURE: ______
STUDENT SIGNATURE: ______
14 PRACTICUM/INTERNSHIP/INDEP STUDY MIDTERM EVALUATION FORM School of Biomedical Engineering
Midterm Evaluation of Student by Practicum Supervisor Student Name ______
Date ______
Technical Knowledge N/A Poor Average Good Outstanding General Education/ ______Technical
Life Sciences ______
Engineering ______
Leadership Qualities N/A Poor Average Good Outstanding Initiative ______
Confidence ______
Resourcefulness ______
Originality ______
Ability to Analyze Problems ______
Adaptability to Situations ______
Ability to Inspire Others ______
Assumes Responsibility ______
Administrative Qualities N/A Poor Average Good Outstanding Organizational Skills ______
Written Skills ______
Communication Skills ______
Time Management Skills ______
Computer Skills ______
15 Ability to Plan ______
Flexibility with Programs ______
Follows Policies/Procedures ______
Orderly and Clean ______
Teaching Qualities N/A Poor Average Good Outstanding Presentation Skills ______
Ability to Teach Activities ______
Ability to Demonstrate ______Activities
Social Qualities N/A Poor Average Good Outstanding Friendly/Courteous ______
Enthusiastic ______
Gets Along with Others ______
Professional Activities N/A Poor Average Good Outstanding Strives for Self Improvement ______
Overall Evaluation of Work ______
Please list the student’s strengths in this practicum experience:
Please list areas in which the student could improve:
Please explain what the student has learned about the clinical environment or clinical practice of biomedical engineering:
Other Comments:
16 Colorado State University School of Biomedical Engineering
Final Evaluation of Student by Practicum Supervisor
To be completed by the practicum supervisor at the end of the semester and reviewed with the student. Please return to the SBME office, 225 Scott Bioengineering Building, or 1376 Campus Delivery, Fort Collins, CO 80523-1376.
Please use the accompanying rating scale to assist the student understand his/her strengths and needs for improvement.
STUDENT NAME: ______
DATE: ______
Rating Scale:
Outstanding…..………………….few other students equal
Good……………….…………….above most other students
Average……………………….….as expected for age and experience
Poor………………………………inferior
N/A……………………………….not applicable
This course is graded as Satisfactory or Unsatisfactory. This student earned the grade of ___S or ____ U
PRACTICUM SUPERVISOR SIGNATURE: ______
STUDENT SIGNATURE: ______
17 Student Name ______
Date ______
Technical Knowledge N/A Poor Average Good Outstanding General Education/ ______Technical
Life Sciences ______
Engineering ______
Leadership Qualities N/A Poor Average Good Outstanding Initiative ______
Confidence ______
Resourcefulness ______
Originality ______
Ability to Analyze Problems ______
Adaptability to Situations ______
Ability to Inspire Others ______
Assumes Responsibility ______
Administrative Qualities N/A Poor Average Good Outstanding Organizational Skills ______
Written Skills ______
Communication Skills ______
Time Management Skills ______
Computer Skills ______
Ability to Plan ______
Flexibility with Programs ______
Follows Policies/Procedures ______
Orderly and Clean ______
Teaching Qualities N/A Poor Average Good Outstanding Presentation Skills ______
18 Ability to Teach Activities ______
Ability to Demonstrate ______Activities
Social Qualities N/A Poor Average Good Outstanding Friendly/Courteous ______
Enthusiastic ______
Gets Along with Others ______
Professional Activities N/A Poor Average Good Outstanding Strives for Self Improvement ______
Overall Evaluation of Work ______
Please list the student’s strengths in this practicum experience:
Please list areas in which the student could improve:
Please explain what the student has learned about the clinical environment or clinical practice of biomedical engineering:
Other Comments: Positions for which you would consider the student qualified upon graduation:
Suggestions to the student:
Suggestions for the Practicum/Internship/Independent Study course:
I would consider this student for employment at my facility: Yes No
19 Colorado State University School of Biomedical Engineering
Final Evaluation of Practicum Experience by Student
DATE ______
FACILITY NAME ______
STUDENT NAME ______
Please elaborate on any of the following questions if you wish
1. Were you satisfied with your practicum/internship/independent study experience? Yes No Please explain
2. Were you fully aware of your duties and responsibilities at your practicum experience?
Yes No
3. Were you aware of the functions and purposes of the facility you worked at?
Yes No
4. Did you feel adequately academically prepared for the practicum experience?
Yes No
5. Did you feel that you were making important contributions to the facility?
Yes No
6. Did you experience any problems as a result of your practicum experience?
Yes No
7. Did you feel free to discuss problems with your practicum supervisor?
Yes No
8. Did you feel that you were treated as a professional?
20 Yes No
9. Were you allowed to make decisions on your own?
Yes No
10. Were you responsible for providing your supervisor with written reports of your activities?
Yes No
11. How would you rate your practicum experience performance?
Poor Average Excellent
Please review with your practicum supervisor and sign.
STUDENT SIGNATURE ______DATE ______
21