CHHS Organization Application

California State University Monterey Bay
COLLABORATIVE HEALTH & HUMAN SERVICES (CHHS) FIELD PRACTICE PROGRAM
100 Campus Center, Ocean Hall Suite C, Seaside, CA 93955-8001
(831) 582-4161 * Fax: (831) 582-3899 * chhsfield@csumb.edu * https://csumb.edu/hhspp

FILL OUT INFORMATION ABOUT SPECIFIC SITES WHERE STUDENTS WILL BE PLACED.

Organization Name *

I. Program Site Information

Note: You only need to fill out general site information if the site where students are serving is a different location than the information provided as the main organization.
(example: Santa Cruz County Health Services fall under an agreement with the County of Santa Cruz)

Street Address

City

State

Zip Code

General Email Address

Website

Social media site

Field Mentor First Name *

Field Mentor Last Name *

Field Mentor Title *

Mentor Degree(s)

Mentor Area(s) of Interest

Field Mentor Email Address *

Are you the main contact for this site? *

Yes

No

Do you want to show Main Contact information to students? *

Yes

No

Are there additional staff at the site who will be Field Mentors? *

Yes

No, just the one listed above

Please list all Mentors at this site:
First Name	Last Name	Title	Phone number	e-mail
First Name	Last Name	Title	Phone number	e-mail

First Name *

Last Name *

Email Address *

II. Specific Site Information

Please provide detailed information in the section below about your site, and what students will be doing at your site.

Students will be searching this information to find a good match with their skills and areas of interest.

Site Information *

Concentration: *

Select any that apply

Social Work

Community Health

Public Administration/ Non-profit Management

Format of Service: *

check all that apply

Remote Service

In-Person Service

Type of Service: *

check all that apply

Direct Client Service

Indirect Service

Please check all of the following CHHS Competencies that the student will be exposed to: *

Refer to this description of CHHS Competencies. Link opens in a new window....CHECK ALL THAT APPLY

What is the maximum number of students your site can accept? *

students

Which language other than English do you prefer students speak?

Please list any important information about Placement dates and times *

Include days and times that students can be on-site.

What are the minimum number of hours per week you require of a student serving at your site? *

hours/week.

Site Requirements

ADA requirements *

Physical and Sensory Requirements

Please provide details about trainings/ staff meetings offered or required *

American Sign Language
Arabic
Armenian
Cambodian
Cantonese
Chinese
Chumash
Dutch
Farsi
Filipino
Finnish
French
Fuchow
German
Greek
Hakka
Hawaiian
Hebrew
Hindi
Hmong
Hokkien
Hungarian
Ilocano
Irish
Italian
Japanese
Khmer
Korean
Laotian
Mandarin
Mixteco
Persian
Polish
Portuguese
Punjabi
Russian
Samoan
Scottish Gaelic
Serbo-Croatian
Somali
Spanish
Swahili
Swedish
Tagalog
Thai
Urdu
Vietnamese
Welsh
Wu
Yiddish