Host Sponsor/Preceptor Intake Form

To assist us in matching students with placements that fit their learning objectives, please provide a brief description of the educational experience your field placement offers. The information below will be placed on the Rush Education and Career Hub Database. The program staff and students use this source extensively to learn about your agency and field placement opportunities. You may update the description as needed.

Host Information

See example here: https://drive.google.com/file/d/1sV2OjIbLKMa07dvAQ-OXFsJWRW_lH0b9/view?usp=sharing

Today's Date

mm/dd/yyyy

Organization/Department Name

Is your organization or agency a clinical or non-clinical area?

Clinical

Non-Clinical

Primary Contact Name

What is the telephone number to your main office?

Contact Number

Contact Email

Will the intern(s) have access to a task manager or secondary contact person?

Please list the name, emails, and extensions of anyone else in your department or agency who will be supervising the intern(s).

Have you hosted an intern before?

Yes

Job Description Questionnaire

Do you have a current student intern job description (HS/College)?

Yes

In order to help us co-develop a student intern job description, please complete the following questions.

Please list and describe any opportunities for interns to observe/assist in an event, surgery, or medical procedure.

Educational Approach

Please briefly describe your department/organization's approach to supervision for youth workers.

What Industry-Wide competencies does your department address?

Department Accommodations

What sessions will your department/organization participate in?

How many interns (max) will you accept each session?

Preferred Shifts

Acceptable Students

Prerequisites

Are you interested in providing stipend support for your interns?

Yes

Comments/Questions

Send me a copy of my responses

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