Provider Interview Acknowledgement Form

Student Name: __________________
Section & Faculty Name:_________________________________
Date of Interview: ________________
Provider Information
Provider Name :

Last

First

M.I.

Credentials:

Title:

(i.e. MS, RN, etc.)

Organization:

Phone Number:

E-mail Address:

Interview Acknowledgement
I _______________________acknowledge that I was interviewed by _____________________on the

(Provider Name) (Student Name)

date listed above. The organization / agency does not endorse the university or the student however, the student learning experience is considered appropriate for educational purposes.

______________________________ _________________

Provider Signature Date Signed

NOTE:

Acknowledgement form is to be returned to the student for electronic submission to the faculty member.

Select a community of interest. It is important that the community selected be one in which a CLC group member currently resides. Students residing in the chosen community should be assigned to perform the physical assessment of the community.

1. Perform a direct assessment of a community of interest using the “Functional Health Patterns Community Assessment Guide.”
2. Interview a community health and public health provider regarding that person’s role and experiences within the community.

Interview Guidelines

Interviews can take place in-person, by phone, or by Skype. Complete the “Provider Interview Acknowledgement Form” and submit with the group presentation.

Develop one set of interview questions to gather information about the role of the provider in the community and the health issues faced by the chosen community. Compile key findings from the interview, including the interview questions used,   and submit with the  presentation.