MSSRP On-Line Preceptor Form

For up to three students

FACULTY INFORMATION*
Faculty name/degree(s):
Faculty Rank*
Faculty department/center:*
Faculty phone:*
Faculty e-mail:*
Type of research project:*
select one or more
- Labroratory
- Clinical
- Outcome/Economics of Health Care
- Epidemiology
- Computational
- Research conducted outside Charlottesville
- Other
Location of research site:*
Number of MSSRP student positions you are offering:*
Title/brief description of project(s), for posting on the MSSRP website:
Supervisor name/degree(s):
Individual responsible for direct supervision of student (if other than preceptor).
Supervisor rank:
Supervisor phone:
Supervisor e-mail:
Financial Information:

The stipend for the 7-week program is $3,200. If your require co-funding by the SOM (up to $1,100), submit an email justification to ddriscoll@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 position until you receive approval of requested partial support.
FINANCIAL CONTACT FOR THE PTAEOs LISTED BELOW
Financial contact name:*
First Last
Financial contact phone:*
Financial contact e-mail:*
SUPPORT FOR STUDENT #1
Total support you will provide for student #1*
Student 1 PTAEO #1:*
Student 1 PTAEO #1 amount:*
Student 1 PTAEO #1 end date:*
MM slash DD slash YYYY
Student 1 PTAEO #2:
Student 1 PTAEO #2 amount:
Student 1 PTAEO #2 end date:
MM slash DD slash YYYY
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:
MM slash DD slash YYYY
Student 2 PTAEO #2:
Student 2 PTAEO #2 amount:
Student 2 PTAEO #2 end date:
MM slash DD slash YYYY
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:
MM slash DD slash YYYY
Student 3 PTAEO #2:
Student 3 PTAEO #2 amount:
Student 3 PTAEO #2 end date:
MM slash DD slash YYYY
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 for. The Office for Research will confirm all matches by e-mail.

MSSRP On-Line Preceptor Form

For up to three students

Financial Information:

FINANCIAL CONTACT FOR THE PTAEOs LISTED BELOW

SUPPORT FOR STUDENT #1

SUPPORT FOR STUDENT #2

SUPPORT FOR STUDENT #3

BY CLICKING ON "SUBMIT" BELOW, YOU ARE: