<p> CALIFORNIA STATE UNIVERSITY, DOMINGUEZ HILLS - SCHOOL OF NURSING</p><p>Learning Contract for BSN 421 (Public Health)</p><p>Student Name: ______Phone______Email address______1. Agency Name: ______Phone______Fax ______Agency Address: ______2. Nursing Administrator / Contact Person: ______3. Preceptor’s Name: ______Preceptor’s Title______Preceptor’s Phone: ______Preceptor’s Email Address: ______4. CSUDH Course Instructor’s Name______Phone______Email Address______In case of emergency, contact CSUDH School of Nursing at 310-243-3596 The number of hours of clinical experience required for this course is:______Beginning Date______Final Date______</p><p>Practice Setting (Check all that apply):</p><p> Acute Care (Type:______)  Home Care  School Health  Adult Day Care  Hospice Care  Substance Abuse Care  Ambulatory Care (circle one)  Long-term Care  Occupational Health primary care specialty clinics  Mental Health  Other: surgery birthing center  Public Health ______ Health Education  Rehabilitation ______</p><p>Preceptor’s Information (may attach curriculum vitae or resume in lieu of completing the information below. ) 1. Educational Preparation: (list schools, dates, and degree conferred) ______</p><p>2. Professional license and/or Certifications (list applicable certificate/license numbers and registration dates) ______3. Present position and number of years in present position: ______</p><p>Preceptor’s signature indicates approval of the Learning Contract and Objectives. Preceptor’s Signature: ______Date:______</p><p>Student’s Signature: ______Date: ______</p><p>A copy of this form should be given to the preceptor and posted to Certified Background. BSN 421 (Public Health) Course Objectives</p><p>Student Name:______Date: ______Version (if resubmitted):_____</p><p>The student needs to discuss with the preceptor and fill out the “Learning Activities” and “Evaluation Measures” in the columns below.</p><p>Course Objectives Learning Activities Evaluation Measures (Activities to Achieve the Objectives) 1. Perform a teaching session 1. Documentation in weekly to clients within the progress notes. community setting. 2. Preceptor Assessment of 2. Develop plans of care Student Progress Form. related to the agency’s mission/goals to its clients. 3. Verbal feedback from 3. In collaboration with preceptor preceptor, determine additional public health services that are provided 4. Verbal feedback from clients. within the agency and ways that the student can gain 5. Completed teaching plan. knowledge and experience in these areas.</p><p>(check those that apply)</p><p>Control and prevention of communicable disease</p><p>Promotion of maternal, child and adolescent health</p><p>Prevention of abuse and neglect of children, elders and spouses. </p><p>Outreach screening, case management, resource coordination and assessment, and delivery and evaluation of care for individuals, families and communities. </p><p>OPTIONAL: Students may add additional objectives to meet their personal professional goals:</p>