Educational Affiliation Agreement Request Form

Educational Affiliation Agreement Request Form

Please complete this form to start the process of initiating a clinical affiliation agreement for Baylor College of Medicine's Undergraduate Medical Education (UME) program or a program within the School of Health Professions (SHP).

For GME-related agreements, please do not complete this form. Contact the GME Office at ask-gme@bcm.edu for assistance.

BCM Sponsor Information

The Preceptor, Chair, or Designee Repsonsible for Learning Experience

Name*

Title*

Department *

Email*

Phone*

Phone

Requesting Date: *

Affiliate Information

Affiliate Name *

(e.g., Hospital, School, Institution)

Affiliate Address*

Affiliate Point of Contact Name:*

Affiliate Point of Contact Email:*

Authorized Signatory for the Affiliate:

Authorized Signatory Contact Email:

Affiliate Point of Contact Phone:*

Phone

Proposed Agreement Information

Is this contract a:*

Select or enter value

Please select BCM Educational Program the contract relates to:*

Select or enter value

Please specify the type of clinical experience:

(e.g., Clerkship, Clerkship-Sub-I, IPE (experience in a Clerkship), Sub-Internship, Elective)

What kind of NP students will be placed at institution?*

(e.g., Pediatrics, Women's Health, adult-gero, psych, etc.)

Number of Clinical Hours for each rotation?*

Estimate of number of students your institution will be requesting to send each semester or year?*

Agreement Effective Date:*

Term of Agreement:*

Select or enter value

Auto Renewal: *

Select or enter value

If an agreement template is available, please attach:

Drag and drop files here or

Have Questions?

Please contact EducationalAgreements@bcm.edu for any UME or SHP-related agreements.

For GME-related agreements, reach out to

ask-gme@bcm.edu

Send me a copy of my responses

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