Qualtrics Survey | Qualtrics Experience Management

Page Loaded

Thank you for your interest in being a field practicum site. Please complete the short form below.

Agency Name

Agency Address

Agency Phone Number

Agency Contact Name (First and Last)

Agency Contact Email Address

Agency Contact Phone Number (if different from above)

Please tell us about your agency as well as opportunities you might be able to offer a field practicum student.

The University of Nebraska does not discriminate based on race, color, ethnicity, national origin, sex, pregnancy, sexual orientation, gender identity, religion, disability, age, genetic information, veteran status, marital status, and/or political affiliation in its education programs or activities, including admissions and employment. The University prohibits any form of retaliation being taken against anyone for reporting discrimination, harassment, or retaliation for otherwise engaging in protected activity. Read the full statement.