MSSRP on-line Student Form

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This form should be completed by the MSSRP preceptor with input from the student.

The preceptor agrees to mentor the student, including overseeing the design/execution of the project, providing appropriate environment and supplies, and collaborating on a work-in-progress and final report.

The student agrees that if s/he participates in the MSSRP, failure to complete all required components of the program will result in an incomplete on his/her transcript, which could prevent his/her graduation.

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STUDENT INFORMATION

Student name: (Required)

Student local address: (Required)

Student phone: (Required)

Student UVA e-mail: (Required)

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PRECEPTOR INFORMATION

Preceptor name: (Required)

Preceptor department: (Required)

Preceptor phone: (Required)

Preceptor e-mail: (Required)

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Direct questions to Dr. Steven Wasserman (sw@virginia.edu) or Ms. Joyce Fortune (jcf9u@virginia.edu).

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MSSRP on-line Student Form

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