Section 1 of 1
PHIP Community Partner/New Site Affiliation Form
All information is required in this form to be completed by signing individual
Organization Name
Organization Name
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Organization Address
Organization Address
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Site Supervisor Name
Site Supervisor Name
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Site supervisor can be the office manager, preceptor, or administrative coordinator for the practice
Answer key
(0 points)
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Site Supervisor Phone Number
Site Supervisor Phone Number
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Office Number if different than above
Office Number if different than above
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Office Fax Number
Office Fax Number
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Site Supervisor Email
Site Supervisor Email
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Website
Website
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Preceptor Name, Title
Preceptor Name, Title
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Name and title of overseeing practitioner
Answer key
(0 points)
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Degree/Credentials Information
Degree/Credentials Information
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
(Ex: MD, American Board of Internal Medicine)
Answer key
(0 points)
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Please provide a list of 5 intern duties or tasks the student will be completing during the internship
Please provide a list of 5 intern duties or tasks the student will be completing during the internship
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
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Please include any health requirements that a student may need prior to starting on site/
Please include any health requirements that a student may need prior to starting on site/
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Ex: Immunizations, TB tests, background checks, Drug tests
Answer key
(0 points)
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Will a dress code be enforced?
Will a dress code be enforced?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Please provide any dress attire requirements on site. (Scrubs, business casual, tattoos, hair, etc)
Answer key
(0 points)
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Are there any student selection requirements?
Are there any student selection requirements?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Ex: Minimum GPA, courses taken, minimum credits, healthcare experience, languages spoken, etc.
Answer key
(0 points)
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