Application to establish an Agreement between DPH and School for Use of Facilities for Clinical Experience
Schools Name
*
Section I: School's Placement Coordinator's Contact Information
School Placement Coordinators Name
*
First Name
Last Name
Title
*
Address
*
Only Physical Address, NO PO Box
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Section II: School Agent's Contact Information
School Agent: School representative signing MOU
School Agent Name
*
First Name
Last Name
Title
*
Address
Only Physical Address, NO PO Box
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Section III: Program(s) that your student will be participating in:
Program(s) that your student will be participating in:
*
Section IV: What will your faculty or staff be using the facility for?
What will your faculty or staff be using the facility for?
Instruction
Evaluation
Site Visits
Section V: Preceptor
Preceptors are staff employed by ZSFG staff or are SFDPH subcontractor (e.g. UCSF) and located at ZSFG facility.
Is this student placement confirmed with the Preceptor? *If yes, please fill out the information below. *If no, please contact appropriate preceptor for availability of a placement opportunity.
*
Yes
No
ZSFG Preceptor's Name
First Name
Last Name
Department/Unit
Preceptor's Phone No.
-
Area Code
Phone Number
Section VI: Start Date of MOU
Start Date of MOU
*
MM/DD/YYYY
Section VII: Insurance requirements from school
DPH requires copies of current insurance certificates for:
General Liability
*
Upload a File
Cancel
of
Policy #
*
Automobile Insurance
*
Upload a File
Required if, student will be driving vehicles during the course of the program
Cancel
of
Policy #
Workers Compensation
*
Upload a File
Workers compensation cannot be waived. Please know that this applies to your University faculty, not students. The reason we need Workers Compensation is that some Universities have faculty that visit students on-site. It is required regardless of the faculty's presence or absence at the site. .
Cancel
of
Policy #
Additional insured endorsements
Upload a File
List the type of insurance to which it pertains with the insurance policy # on endorsement
Cancel
of
Comments
E.g. Mail documents to PO Box 0000
For any questions or concerns, please contact Priyanka Karki, Student Placement Coordinator at (415)206-4655 or via email at priyanka.karki@sfdph.org
Submit Form
Print Form
Should be Empty: