MSSRP on-line preceptor form (for up to three students)

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MSSRP on-line preceptor form (for up to three students)

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FACULTY INFORMATION

Faculty name/degree(s): (Required)

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Faculty rank: (Required)

Faculty department/center: (Required)

Faculty phone: (Required)

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Faculty e-mail: (Required)

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Type of research project (select one or more): (Required)

Laboratory

Clinical

Outcomes/economics of health care

Epidemiology

Computational

Research conducted outside Charlottesville

Other

Location of research site: (Required)

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Number of MSSRP student positions you are offering: (Required)

Title/brief description of project(s), for posting on the MSSRP web site (Required)

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INDIVIDUAL RESPONSIBLE FOR DIRECT SUPERVISION OF STUDENT (if other than preceptor):

Supervisor name/degree(s):

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Supervisor rank:

Supervisor phone:

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Supervisor e-mail:

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FINANCIAL INFORMATION: The stipend for the 7-week program is $2,800. If you require co-funding by the SOM (up to $1,000), submit an e-mail justification to ssw3an@virginia.edu. We can co-fund a single student per faculty member.

The SOM will pay all summer session fees. Please do not promise a student a position until you receive approval of requested partial support.

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FINANCIAL CONTACT FOR THE PTAEOs LISTED BELOW

Financial contact name: (Required)

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Financial contact phone: (Required)

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Financial contact e-mail: (Required)

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SUPPORT FOR STUDENT #1

Total support you will provide for student #1 (Required)

Student 1 PTAEO #1: (Required)

Student 1 PTAEO #1 amount: (Required)

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Student 1 PTAEO #1 end date:

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Student 1 PTAEO #2:

Student 1 PTAEO #2 amount:

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Student 1 PTAEO #2 end date:

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SUPPORT FOR STUDENT #2

Total support you will provide for student #2

Student 2 PTAEO #1:

Student 2 PTAEO #1 amount:

Student 2 PTAEO #1 end date:

/ /

Student 2 PTAEO #2:

Student 2 PTAEO #2 amount:

Student 2 PTAEO #2 end date:

/ /

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SUPPORT FOR STUDENT #3

Total support you will provide for student #3

Student 3 PTAEO #1:

Student 3 PTAEO #1 amount:

Student 3 PTAEO #1 end date:

/ /

Student 3 PTAEO #2:

Student 3 PTAEO #2 amount:

Student 3 PTAEO #2 end date:

/ /

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BY CLICKING ON "SUBMIT" BELOW, YOU ARE:

- Agreeing to mentor the MSSRP student(s) described herein. This includes overseeing the design/execution of the project(s), providing appropriate environment and supplies, and collaborating on a work-in-progress and final report.

- Authorizing the SOM Office for Research to deduct payment from the PTAEO(s) listed above.

Students will contact you directly to discuss their participation on your project(s). Once you have selected one, s/he and you should complete a student form. The Office for Research will confirm all matches by e-mail.

MSSRP on-line preceptor form (for up to three students)

MSSRP on-line preceptor form (for up to three students)

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