PHIP Community Partner/New Site Affiliation Form

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All information is required in this form to be completed by signing individual

Organization Name *

Organization Address *

Site Supervisor Name *

Site supervisor can be the office manager, preceptor, or administrative coordinator for the practice

Site Supervisor Phone Number *

Office Number if different than above

Office Fax Number

Site Supervisor Email *

Website *

Preceptor Name, Title

Name and title of overseeing practitioner

Degree/Credentials Information

(Ex: MD, American Board of Internal Medicine)

Please provide a list of 5 intern duties or tasks the student will be completing during the internship *

Please include any health requirements that a student may need prior to starting on site/ *

Ex: Immunizations, TB tests, background checks, Drug tests

Will a dress code be enforced? *

Please provide any dress attire requirements on site. (Scrubs, business casual, tattoos, hair, etc)

Are there any student selection requirements? *

Ex: Minimum GPA, courses taken, minimum credits, healthcare experience, languages spoken, etc.

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