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 you require co-funding by the SOM (up to $1,100), submit an email request with justification to Joyce Fortune . If you are requesting co-funding by the School of Medicine, please do not promise a student position until you receive approval of requested partial support.

The SOM will pay all summer session fees.
FINANCIAL CONTACT FOR THE WORKTAGS LISTED BELOW
Financial contact name:*
First Last
Financial contact phone:*
Financial contact e-mail:*

If you are unsure whether your worktags are SIS-active, please email askfinance@virginia.edu or check with your OSP contact if relevant. Other types of worktags (FN-, FD-, BU-) have default values in SIS and should not be submitted.
SUPPORT FOR STUDENT #1
Total support you will provide for student #1*
Student #1 Cost Center (ccXXXX) (Must be SIS allowed)*
Student #1 Fund number (ONE number, either GF-, GR-, DN-, PJ-)
Student # 1 Activity (optional)
Student 1 Assignee (optional)
SUPPORT FOR STUDENT #2
Total support you will provide for student #2
Student #2 Cost Center (ccXXXX) (Must be SIS allowed)
Student #2 Fund number (ONE number, either GF-, GR-, DN- PJ-)
Student #2 Activty (optional)
Student #2 Assignee (optional)
SUPPORT FOR STUDENT #3
Total support you will provide for student #3
Student #3 Cost Center (ccXXXX) (Must be SIS allowed)
Student #3 Fund number (ONE number, either GF-, GR-, DN-, PJ-)
Student #3 Activity (optional)
Student #3 Assignee (optional)
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 Worktag(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 the On-Line Student Match Form. 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 WORKTAGS LISTED BELOW

SUPPORT FOR STUDENT #1

SUPPORT FOR STUDENT #2

SUPPORT FOR STUDENT #3

BY CLICKING ON "SUBMIT" BELOW, YOU ARE: