PART C – AGENCY INFORMATION (Must be completed in full)

AGENCY for SCHOLARLY PROJECT

The Agency where the Scholarly Project will be implemented may be different from the preceptor's employing agency.

Student Name ___

1/2

Agency Information

formation

The Name of the agency, clinic, group, or entity where Scholarly Project implementation will occur:

Contact person at agency:

Telephone Number with area code: ___

Mailing address of Office Manager/Administrator: ___

(if different from agency mailing address)

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Country

City State Zip Code County

Starting Date of Experience: ___

(First date possible you will be in this clinical setting)

Anticipated Length of Experience: ___

Circle Correct Descriptor of Agency:

Rural Clinic Academic Medical Center Clinic

Inner City Clinic School

Specialty Clinic Private Practice Government Agency

Hospital Church

Public Health Department Clinic Hospital Professional Organizations Church

Other ___

Volunteer Organization

Type of Experience:

□Educational

□ Clinical

□ Direct

□ Indirect