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Public Health Internship Program Application

Internship Program Application (HDInternship@pima.gov)

I. APPLICANT INFORMATION

Name  *Phone 
Address City 
State Zip 
E-mail  *Referred by
Emergency Contact Emergency Phone 

II. STUDENT INFORMATION

College/University Name (if not enrolled, go to SECTION III): 

Current Degree Program (Certificate, Associates,Bachelors, Masters or PhD: 

Field of Study: 

Are you seeking an internship for college credit or course/program requirement?  Yes   No
If yes, submit forms/documents related to your internship plan at HDInternship@pima.gov

College Preceptor Name:  

Requested Start Date:  

Total # hours of request:    # of hours available per week:  

Are you applying for a PCHD internship Project?  Yes   No
If yes, specify position title:

If you have your own project or project idea, please describe:

III. GOALS

Please provide a short description of what you hope to accomplish while participating in a public health internship or volunteer experience at PCHD. 

IV. EXPERIENCE & SKILLS

List any relevant skills, training, certifications or licenses you possess. 

V. PREFERENCES & AREA OF INTEREST

Top 2 interest areas or listed opportunities you are applying for:  1. 2. 

Of the following, please select the program areas that would be most appropriate for your public health experience needs:

Non-focused/General

 Event Support   Office Support   Community Surveying   Resource Development   Personnel   Vital Records

Clinical Services

 Infectious Disease   Tuberculosis Clinic   Oral Health Screening   Reproductive Health   Immunizations  
  Public Health Nursing    HIV/STD Screening, Surveillance & Investigation    Organization/Regulatory Compliance

Community Based Health Services

 Maternal & Child Health   Nutrition Assistance   HIV Prevention & Education   School Based Programs   Adolescent Health Services   Prescription Drug Misues Prevention   Tobacco & Chronic Disease Prevention & Education   Nurse Family Partnership-Home Visitation  

Community Health Assurance

 Environmental Health   Health & Food Safety   Disease Surveillance   Public Health Emergency Preparedness   Communicable Disease Investigation (foodborne illness, measles, Zika, etc.)

Health Administration

 Finance   Grants Management   Media and Public Relations   Workforce Development   Health Equity  
Community Improvement Planning  Community Engagement & Coalition Building  Performance Improvement  

VI. VOLUNTEER/INTERN AGREEMENT

POLICIES AND PROCEDURES

As a PCHD volunteer/intern, I AGREE TO:
  • Support the mission, vision, goals, efforts and official positions of PCHD.
  • Promote goodwill by handling my responsibilities and contacts with staff, other volunteers, customers and visitors in a spirit of courtesy and cooperation.
  • Observe:
    • The Drug-Free Workplace Act of 1989;
    • Pima County policies that prohibit workplace harassment;
    • Pima County Privacy and Confidentiality rules;
    • Pima County IT Program policies;
    • Pima County policies related to disciplinary action, attendance, and rules of conduct;
    • The most current communication plan for reporting concerns with policies, practices or procedures; and
    • All policies and directives required by PCHD.

SAFETY, SECURITY, and CONFIDENTIALITY

As a PCHD volunteer/intern, I AGREE TO:
  • Report to my volunteer job physically and mentally fit for duty.
  • Observe all safety and security rules.
  • Report accidents, injuries, fire, theft or other unusual incidents immediately after the occurrence or discovery.
  • Refrain from using PCHD property, services or supplies for personal reasons unless given prior permission by the site supervisor.
  • Deal fairly with all PCHD colleagues, co-workers, supervisors, customers, visitors, and volunteers, without regard to their gender, race, ethnicity, religion, creed, age, sexual orientation, marital status, national origin, ancestry, citizenship, military status, veteran status, handicap or disability.
  • Contact the Volunteer/Internship Coordinator or another appropriate site supervisor immediately if I feel discriminated against or harassed in connection with my volunteering/internship.
  • Hold harmless PCHD, its agents, employees, directors and insurance carriers from any and all claims, damages and judgments which I may have now or in the future against the PCHD in all matters pertaining to my services as an agency volunteer, including, but not limited to, personal injury.

CONFIDENTIALITY and CONFLICT OF INTEREST

As a PCHD volunteer/intern, I AGREE TO:
  • Maintain and safeguard the confidentiality of all business, donor, employee, volunteer and client records, credit and financial information, and/or any information relating to the operation of the agency that is not known or readily available to the general public.
  • Avoid engaging in any conduct that is, or could be, perceived as a conflict of interest.

I understand that this volunteer/intern experience is unpaid, and by, signing and submitting this application, I agree to abide by the policies and procedures of PCHD during my time as a volunteer/intern, conforming to all rules and regulations commonly applied to employees of the agency, including but not limited to, safety, discrimination, harassment, confidentiality and position statements.

By submitting this application, I understand that failure to abide by these policies, procedures and rules is grounds for disciplinary action, up to and including, the dismissal from PCHD’s volunteer/internship program.

SIGNATURE

Signature *    Date *  
>Referred from Page: 



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