**Confidential**
COMHE Undergraduate
Field Placement Student Assessment
(Part One)
In order to help you select a
field placement site, please respond to the following questions and bring to
your first meeting with the Field Placement Coordinator. You only need to complete this form once, at
time of first enrollment in field placement.
1. Please describe your current skills or
knowledge in the field of community health education.
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2. Please describe the skills or knowledge you
would like to develop in the field of community health education.
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3. Please describe the ideal setting in which
you would like to work once you complete your degree (e.g., hospital, CBO,
school, public agency, corporate office, international organization).
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4. What is the ideal job title you would like to
hold?
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5 Please describe the type of community in which you would like to work to make
a difference (e.g., a specific neighborhood, a specific group of people
effected by a particular health issue).
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6. Please describe any special considerations or
constraints you might have in regard to a field placement (e.g., a physical
challenge, child care, geographic barriers, religious/political etc.).
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Field Placement Student Assessment
(Part Two)
1.
How many years
have you worked or volunteered in the field of community health education? [ ] 0 [
] 1-2 [
] 3-5 [ ] 5 or more
2.
Are you
interested in a field placement outside of
3.
Are you
interested in international work? Yes
[ ] No [ ]
4.
What hours during
the week are you available for field placement?
[ ] daytime
only
[ ] evenings
only
[ ] days
or evenings
[ ] weekends
only
[ ] flexible
hours
5.
If you work, is
your current position in the field of community health education?
Yes
[ ] No [ ]
5a.. If yes or no, please describe what you
do:____________________________
______________________________________________________________________
______________________________________________________________________
6.
Do you have a
current resumé?
Yes [ ] No [ ] If yes, please
attach a copy. If no, please prepare one
and submit.
Your Name: ________________________________ Date Submitted: ______________