MOU application for student placement

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
Should be Empty:

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