Oregon SEARCH Placement Interest Form

The Oregon SEARCH program, funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration, is designed to match clinicians in training with sites providing primary care services to underserved populations. Students will be placed from all over the country with an emphasis on NHSC Scholars and students studying in Oregon. Your participation is essential to making this program successful.

In appreciation for your organizations commitment to training your future providers, we are offering remuneration to your organization for each learner you host in addition to the hosted student’s involvement in a clinic or community based service activity that supports the hosting clinic’s mission.

Name and Address of Clinic or Organization:

Address of site(s) where students/residents will be placed (if different from above):

Brief description of each clinic site, its internal culture, patient demographics and the community in which it resides:

Name of Administrator or contact person (title) for student rotation logistics:

Phone Number:

Email Address:

We are interested in having the following students/residents work at our clinic/organization: (check all that apply):

Physician Assistant Students
Nurse Practitioner Students
Medical Students
Dental Students
Family Medicine Residents

We are able to work with students :

Year Round
Summer Only
Only Occasionally – Specific Time Of Year

How many students can you take in a calendar year?

We are willing to help find housing for students coming to our clinic (the program will pay for student rent):

Yes
No

All students will need to complete a clinic or community based project (e.g. diabetes education or study, dental education, outreach to elders, study of pregnant women, mentorship or tutoring for high school students, community needs assessment). Is there someone in your clinic who could provide the learner with guidance on this sort of project?

Yes
No

Speaking a language other the English is:

Mandatory
Helpful
Not Necessary

If yes, which languages?

Please list in general, the services offered at your clinic:

Please describe the population seen at your clinics in terms of income, ethnicity, race or other characteristics, which may be helpful in describing the placement:

Please list all the clinicians, and their profession who will work with students/residents:

Comments, additional information:

Verification: