Capstone Plan Approval Form

Instructions: This form is to be completed in consultation with Sara Solomon, Deputy Director of CPHI, and a community preceptor from a community-based fieldwork site. A community preceptor is a professional working at the selected community based fieldwork site who has agreed to work with and advise you until the completion of your 125 hour placement. Please complete and return the original form to Sara Solomon ([email protected]). Any changes to your fieldwork plan must be documented by completing and submitting a revised plan (via a revised form or an addendum to the original form).

Student Name: Fieldwork Project Site: (First Name, Last Name)

Fieldwork Overview & Learning Objectives for Core Competency Outcomes: Please provide:  A brief description of the organization at which you will be fulfilling your fieldwork requirement including a description of the target population served by the organization/project and the mission of the organization;  A description of the proposed project/a scope of work;  An explanation of how this project is public health practice and contributes to population health results  A description of the learning objectives and core competencies that will be strengthened; o Be sure to address track specific competencies  A listing of agreed upon deliverables if applicable;  A timeline for the project; and  A description of the roles and responsibilities of the student and the community preceptor. Please develop the above in collaboration with your community preceptor. You can attach the Fieldwork overview to this form.

Community Preceptor Information: Name: ______

Organization: ______

Title: ______Address: ______

Email: ______Phone: ______

Community Site Information (if different from above) Organization: ______

Address: ______Contact Information: ______

The Student will spend a minimum of 125 hours under the Community Preceptor’s supervision in the field. By signing this document, I approve of the above named Student’s fieldwork plan (attached) and agree to work with the student until the completion of his/her placement.

Deputy Director, CPHI: ______(Sara Solomon) (Signature/Date)

Community Preceptor: ______(print) (Signature/Date)

Student: ______(print) (Signature/Date)