Institutional Application for Internship/Rotations

with Onondaga County Health Department

Name of Institution:
Purpose of Internship/Rotation at Onondaga County Health Department (OCHD):
What type of student: Undergraduate Graduate Medical – what year? Resident – what specialty? Other – Specify:
How long is the internship/rotation? Estimated number of students: Fall semester Spring semester Other – Specify:
Who will provide the grade:
Is this a credit course? Yes No Other: If so, how many credits:
Will this be for a degree or certificate? Yes No Name of degree/certificate:
Name of the faculty member teaching the course (provide contact information, including phone & email):
What are the learning objectives of this course?
What is the responsibility of OCHD?
Do we have a current MOU & liability coverage with the organization?
When is your proposed start date?