Health Care Management Major

Interview Form

____________________________________has concluded an interview with me regarding possible placement in my agency as an intern for the

___________________________________  semester.

This placement will be:    _______Acceptable  __________Unacceptable

(If unacceptable, we would appreciate knowing your reasons for this decision, in order to improve our advising of future students):

Agreement if placement is acceptable:

I understand that full-semster fieldwork students (interns) are expected to work a minimum of 450-500 hours during the semester at their agencies (matching the normal full-time worker's hours at a given placement). Our initial plan is to have this student work the following schedule (please indicate hours/day & days/week, including likely evenings and/or weekend activities). The agency will promptly notify the fieldwork coordinator if these hours/days need to change:

________________________________________________________________________________

Signature of

Student Intern___________________________________________Date:_________________

Signature of

Agency Supervisor: ______________________________________Date: _________________

Agency: _______________________________________________________________________

Return to:

Sharon Buchbinder, RN, PhD
Professor and Coordinator
Health Care Management Program
Department of Health Science
Towson University
8000 York Road
Towson, MD  21252-0001
410/704-4219 (Tel)
410/704-4670 (Fax)

Email: sbuchbinder@towson.edu

Department of Health Science
Burdick Hall, Room 141

Hours: Monday–Friday, 8:30 a.m.–5 p.m.

Phone: 410-704-2637
Fax: 410-704-4670