Department / Organization:

Branch
Directorate
Division
Group

Mailing Address:

Primary Supervisor:
Name
Title
Telephone
Fax
Email

Alternate Supervisor #1
Name
Title
Telephone
Fax
Email

Alternate Supervisor #2
Name
Title
Telephone
Fax
Email

Why do you want to supervise a Field Epidemiologist for two years?

Available Support:
List the available technical resources and administrative support, including Field Epidemiologist alumni

Orientation to Placement:
Describe how you would orient a Field Epidemiologist to your area; what specifically would you and other staff do to prepare for a Field Epidemiologist’s first week on the job?

Access to Supervision:
On average, how much duty travel do you do annually?

If you were unavailable for an extended period of time ( 2 weeks) because of vacation, duty travel, leave of absence, etc., what specific provisions would you make to ensure that a Field Epidemiologist placed with you is adequately supervised?

Coaching/Mentoring/Feedback:
Describe your approach to supervising a Field Epidemiologist; how would you provide feedback?

Scope of Placement:
Summarize the mandate, roles and responsibilities of department / organization

Range of Opportunities:
Summarize the range of activities in which a Field Epidemiologist may become involved; indicate the level of responsibility the Field Epidemiologist might have with various activities; specifically address opportunities for field investigations; indicate how these activities relate to the Field Epidemiologist’s PEGs (see attached document)

Proposed Surveillance Projects:
Identify specific surveillance-related project(s)

NOTE: In previous years, PEG#3 focused on the evaluation of a health event under surveillance. At the placements’ request, this has been broadened to include the design, implementation, revision or evaluation of public health surveillance.

Strength of Placement:
Feel free to sell your placement

Potential Limitations of Placement: