• 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

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  • Section II: School Agent's Contact Information

    School Agent: School representative signing MOU
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  • 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

    Preceptors are staff employed by ZSFG staff or are SFDPH subcontractor (e.g. UCSF) and located at ZSFG facility.
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  • Section VI: Start Date of MOU

  • Section VII: Insurance requirements from school

    DPH requires copies of current insurance certificates for:
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  • 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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