Applied Practice Experience Approval Form

To be completed by students who entered the MPH Program Summer 2025 or before.

If you entered the MPH Program Fall 2025 or after please complete THIS approval form.

Please allow a 7-10 day turnaround time for feedback upon submission. Please feel free to email Nekia to let her know that your summary form has been submitted.

Instructions: This form is to be completed in consultation with a community preceptor from a community-based APE site. A community preceptor is a professional working at the selected community-based fieldwork site who has agreed to work with and advise students until the completion of placement. Fieldwork should be mutually beneficial to the student and the community organization. Any major changes to the fieldwork plan must be documented by revising this form. A NEW approval form needs to be submitted for each fieldwork experience.

Approval forms must be shown to the preceptor within the first week of placement at the latest. After electronic submission here, you will receive an email to confirm approval of this placement. This placement is only approved after you receive the confirmation email within one week of submission.

At the completion of the project(s), students will submit a summary form which must include a timelog AND a minimum of two deliverables (outlined below).

YesNo

Date*

Date

Name*

First NameLast Name

Email*

example@example.com

Student ID Number*

GeneralistGlobal HealthOne HealthEpidemiology

Select your Required Track Elective (RTE) - If you have not taken an RTE select none.*

List additional RTE's below.

If you are on the Global Health, One Health or Epidemiology Track how will this fieldwork be directly related to your MPH track? If on the Generalist track type n/a. *

YesNo

If you are a dual degree student, which other program are you pursuing as part of your dual degree?

YesNo

MPH Advisor*

APE Host Site (e.g. CHOP PolicyLab)*

APE Host Site Location (City/State/Country)*

APE format (Fully In-person/Hybrid/Fully Remote)*

Start Date:*

Date

Anticipated End Date:*

Date

Expected Graduation Date:*

Date

Projected Work Hours/Schedule*

NoYes

Preceptor Name*

First NameLast Name

Preceptor Email*

example@example.com

Preceptor Position Title*

List any additional preceptor names, emails and positition titles below.

Description of the organization: Include organization mission and target population. If the site is university-affiliated, explain how the focus is on community engagement and list any external partners below.*

Is this site University-affiliated? If so please include external organizations/partners. If not University-affiliated please type n/a. *

NoYes

If this APE site will be used as a community partner for your Capstone Project how will your APE project differ from your Capstone Project? If this does not apply type n/a*

Please give an overview of the APE project in which you will be working on.*

Please list the specific APE duties in which you will be fulfiling.*

Describe your specific fieldwork activities, duties, role, and responsibilities.

Anticipated Deliverables*

Describe the deliverables or products you plan on developing for your host site.

APE Timeline*

Provide a timeline outlining your proposed work schedule, completion of major project components, deliverables, etc.

Preceptor Duties*

Describe how you will be working with your preceptor and anticipated meeting frequency.

Applied practice experiences must map to at least 5 MPH Competencies, outlined by the Council on Education for Public Health (CEPH).

Select 5 MPH Competencies that you will obtain through your applied practice experience and explain how you plan to satisfy each competency. Of the 5 competencies you select, at least 3 must be foundational competencies. Track competencies you select outside of the 22 Foundational Competencies MUST be from your Required Track Elective (RTE) class in which you have taken. To check which track competencies map to your RTE, please check this grid for track competencies on the MPH Home Base.

Your approval form should indicate which of your duties and anticipated deliverables will satisfy your selected competencies. At the end of your placement, you will submit a minimum of 2 "deliverables" that satisfy your selected competencies. ALL COMPETENCIES MUST BE MET, this may mean submitting more than 2 deliverables!

*PLEASE NOTE* Required Track Elective competencies (Generalist, Global, One Health, Epidemiology) can only be selected in competency sections 4 and 5.

Foundational Competency 1*

Describe your duties, projects, assignments, etc... that will satisfy competency 1.*

What is your anticipated deliverable to satisfy competency 1?*

Foundational Competency 2*

Describe your duties, projects, assignments, etc... that will satisfy competency 2.*

What is your anticipated deliverable to satisfy competency 2?*

Foundational Competency 3*

Describe your duties, projects, assignments, etc... that will satisfy competency 3.*

What is your anticipated deliverable to satisfy competency 3?*

Foundational or Track Competency 4 (Note: if you choose a track competency, it must map to an Required Track Elective course in which you have takens)*

*SCROLL DOWN FOR COMPLETE LIST OF COMPETENCIES*

Describe your duties, projects, assignments, etc... that will satisfy competency 4.*

What is your anticipated deliverable to satisfy competency 4?*

Foundational or Track Competency 5 (Note: if you choose a track competency, it must map to your Required Track Elective course in which you have taken) *

*SCROLL DOWN FOR COMPLETE LIST OF COMPETENCIES*

Describe your duties, projects, assignments, etc... that will satisfy competency 5.*

What is your anticipated deliverable to satisfy competency 5?*

Attach the completed Fieldwork Approval Form Template signed by you and your preceptor.

Browse Files

I agree to the terms outlined in this approval form.I have shared this information with my community preceptor and they agree to the terms outlined in this approval form.I have confirmed my preceptor’s policy on AI usage and am aware of whether I’m permitted to use it.

Applied Practice Expereince Approval Form

APE Preceptor Information

APE Site Information

Applied Practice Experience Overview