APP Student Placement Intake Form

Please fill out this form completely and accurately!

Any incomplete forms will be returned to the requestor for completion.

Request Date*

Student's Last Name*

Student's First Name*

Student's Email Address*

Student's Phone Number

Phone

Student's Home University*

Student's Home University Program*

NP

PA

Midwife

CRNA

Start Date of Clinical Rotation*

Estimate is okay, we just want to make sure the Affiliation Agreement covers the estimated dates. Please note Affiliation Agreements do not auto renew.

We recommend a start date of at least 2 weeks out, as it will take some time to acquire your EID and account access to the resources for your rotation.

End Date of Clinical Rotation

Estimate is okay, we just want to make sure the Affiliation Agreement covers the estimated dates. Please note Affiliation Agreements do not auto renew.

Student's Final Decision Deadline Date

Can be an estimate of when the student's home university requires the student to submit their placement information.

Student's Home University Program Director/Contact*

Please provide Name and credentials

Student's Home University Contracts/Procurement Contact*

Please provide name and credentials

Is the student currently a UCSF Employee?*

Yes

No

If known, Employee/Student department cost center?

Does the Student have a confirmed UCSF Preceptor?*

This form will not submit if you do not have a confirmed Preceptor. The Office of Advanced Practice does not place students with UCSF Preceptors, it is the student's responsibility confirm availability of their UCSF Preceptor prior to inquiring about a valid affiliation agreement.

Yes

If the Student does not have a UCSF Preceptor please do not complete this form.

The Student can fill out this form after a relationship between the student and a UCSF APP is established. Again please note that the Office of Advanced Practice does not place students with preceptors, it is the student's responsibility to confirm availability of their UCSF preceptor prior to requesting affiliation agreement requests..

Student Vaccination Status*

Vaccination status must be on record at the Student's home University. Effective 9/1/2021 vaccination is required of all individuals as a condition of Physical Presence at any University of California Location or Program as set forth in the UC Policy: SARS-CoV-2 Vaccination Program unless they have been granted an Exception or Deferral. A person is considered “fully” vaccinated when two weeks have passed since they completed a COVID-19 Vaccine series (for example, 1 dose of the Janssen/J&J vaccine, or 2 doses within no more than 12 weeks of the Moderna or Pfizer vaccine); as well as any boosters consistent with manufacturer instructions and applicable agency approval, authorization, or listing.

Fully Vaccinated (see definition above)

Partially Vaccinated (less than two weeks since last dose or only has had one of two doses)

Unvaccinated

Approved Deferral - Religious exception

Approved Deferral - Disability exception

Approved Deferral - Medical condition exception

Approved Deferral - Pregnancy exception

I attest that the information above is true. If anything changes, I will contact the Office of Advanced Practice Providers at advancedpractice@ucsf.edu*

Send me a copy of my responses