Health Information Management Program

PROFESSIONAL PRACTICE EXPERIENCE PROPOSAL (Student)

The student must submit a completed PPE Proposal to the HIM Program Chair at least 12 weeks prior to the
proposed start date.

Student Name: Date:

Academic Term Requested for PPE:

Site of PPE (Name and address of facility):

Site Manager:
Name:
Title/Department:
Email:
Phone:

Proposed Project (i.e. Quality Improvement, Implementation, Re-design, etc.):

Specific Learning Outcomes (i.e., student will create, design, develop, integrate, evaluate, manage, recommend, etc.):
1.
2.
3.
Project Deliverables (i.e. Report, Portfolio, Journal, RFP, Presentation, White Paper, etc.):
1.
2.
3.

Describe your proposed work schedule and plan for completing the PPE (minimum of 80 hours):

Approval:
Site Manager Signature: _________________________________________ Date: ________________
Printed Name: _________________________________________________

HIM Program Chair Signature: ____________________________________ Date: ________________

Printed Name: _________________________________________________