Form

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
Is for faculty only, if they intend to be onsite with students. 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
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Application to establish an Agreement between DPH and School for Use of Facilities for Clinical Experience

Section I: School's Placement Coordinator's Contact Information

Section II: School Agent's Contact Information

Section III: Program(s) that your student will be participating in:

Section IV: What will your faculty or staff be using the facility for?

Section V: Preceptor

Section VI: Start Date of MOU

Section VII: Insurance requirements from school