• Student Placement Form

    Please have your demographic information, professional license number, academic programs information, school's contact information, immunization records, and preceptor contact information prior to complete this form.
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  • Education

    Only include applicable degree for student placement experience
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  • School's Contact Information

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  • Precepting Department/Unit

  • Health Requirements

    Students are required to provide proof of immunizations, screening and/or titers of below BEFORE starting placement. Although not required, we strongly recommend Hepatitis B screening and vaccination. For clinical students, health screening is required at the beginning of every clinical rotation. Complete below and show proof to the preceptor/ZSFG STAFF when requested. Actual records are not needed; do not attach.
  • Vaccination Attestation

    If you indicate "No" on any of the below questions, please contact your preceptor to proceed further.







  • Emergency Contact

    Please provide a contact person in case of an emergency while on the ZSFG campus or affiliated campus
  • Oath of Confidentiality

    As a condition of clinical placement, conducting research, a student internship or the observation of patient care at Zuckerberg San Francisco Hospital and Trauma Center, I agree not to divulge any information obtained in the course of such training or research to unauthorized persons, and not to public or otherwise make public any information regarding persons who have received resources such that the person who received services is identifiable. I further agree not to divulge or public general patient information or statistics without prior authorization from my preceptor or hospital administration. I further agree to hold in strict confidentiality on all matters discussed on Medical Staff or hospital committee meetings to which I might be privy. I recognize that the unauthorized release of confidential information may make me subject to civil action under provisions of the Welfare and Institutions Codes.
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  • ZSFG COVID-19 Standards for Students, Instructors, and Faculty

  • Orientation

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  • Student Declaration

    I certify that the information provided on this form is true, accurate and complete. I agree to provide the immunization/screening records upon the hospital’s request. I understand that any false information will cause my disqualification in any programs on the Zuckerberg San Francisco General Hospital (ZSFG) campus and affiliated clinics. I recognize that all confidential information obtained or observed at ZSFG is in confidential nature. I agree, that at all times, to ensure the confidentially of all sensitive information I have contact with, comply with applicable laws and maintain patient privacy. I understand that failure to comply with any of the above requirements may result in cancellation of my instruction agreement. I further attest that I have received appropriate written material and introduced to the hospital and the appropriate department/unit/clinic protocol and standards.
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  • Submission

    Please click the Print Button below and submit this form directly to your assigned preceptor (ZSFG staff contact or department). If you have any questions regarding this form, contact your preceptor (preferred) or Department of Education and Training at 628.206.4655
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