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PHIP Community Partner/New Site Affiliation Form
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Organization Name
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Organization Address
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Site Supervisor Name
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Site Supervisor Phone Number
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Office Number if different than above
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Office Fax Number
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Site Supervisor Email
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Website
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Preceptor Name, Title
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Degree/Credentials Information
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Please provide a list of 5 intern duties or tasks the student will be completing during the internship
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Please include any health requirements that a student may need prior to starting on site/ 
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Will a dress code be enforced? 
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Are there any student selection requirements? 
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