Initiating a University – Agency Contract
(Internship Agreement)
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California State University, Fresno
Department of Nursing
2345 E. San Ramon Ave. M/S MH25
Fresno, CA 93740-8031
Phone: 559-278-2041
Fax: 559-278-6360
INITIATING A UNIVERSITY & AGENCY AGREEMENT
(Student Intern Agreement)
Date: ____________________
STUDENT INFORMATION
Student Name: _____________________________________ Student ID: _______________
Address:
_____________________________________________________________________________
City
State
Zip
Phone: _____________________________
Semester: _________ (circle program)
Email: ________________________________
BSN
RN-BSN
MSN
School Nurse Credential
PRECEPTOR INFORMATION
Preceptor: __________________________ (circle one) RN MD MSN NP School Nurse
Phone: __________________ Fax: __________________ Email: ______________________
Contact Person (signing agreement): _____________________________________________
Phone: __________________ Fax: ___________________ Email: ______________________
Agency (School District/COE): __________________________________________________
Street Address: _______________________________________________________________
City: _____________________________ State: _________ Zip Code: ________________
This form MUST be completed before contacting the Department of Nursing for contract agreement
process. Contracts can take up to a month or longer to be processed. If you have any questions regarding
contracts (pending, active, or new) please contact the Department of Nursing at (559) 278-2041.
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INITIATING A UNIVERSITY & AGENCY AGREEMENT (p. 2)
Steps to Obtaining a University/Agency Agreement
1.
2.
3.
Find a qualified preceptor with whom you can work.
Contact the Contract Coordinator at (559) 278-5283 to see if there is a current University/Agency
agreement in place with that agency.
If there is not a current agreement in place, complete the information requested on the first page and
mail, fax, or return the completed form in person to the Contract Coordinator in the CSU Fresno
Department of Nursing.
Note: Be sure that all of the requested information is on the form.
4.
5.
6.
7.
Once the agreement has been created by the Contract Coordinator it will be sent to the contact
person at that agency for the appropriate signature.
The contact person at that agency will need to return the signed agreement to the Contract
Coordinator in the CSU, Fresno Department of Nursing.
Once the signed agreement has been returned to the CSU Fresno Contract Coordinator, it will be
sent to CSU Fresno Director of Procurement & Support Services, Risk Manager of Environmental
Health & Safety, and the Chair of the Department of Nursing for signatures.
After the agreement has been signed by all three parties, a copy will be sent back to the agency and
the student may begin his/her practicum experience.
*Note- Please allow at least one month for the contract to be finalized. The university also accepts the
agency‟s own contract, but this may take longer (2-6 months) for processing. If an agency
contract/agreement is to be used, the contact person at that agency will need to send that
contract/agreement to the attention of:
Contract Coordinator
CSU Fresno Department of Nursing
2345 E. San Ramon Ave. MS MH 25
Fresno, CA 93740-8031
If the agency contract is used, there must be a place for three (3) signatures for the following CSU Fresno
responsible parties:
Margie Phillips
Director, Procurement & Support Services
Dr. Michael Russler
Chair, Department of Nursing
Steve Martinez, Risk Manager, Environmental Health & Safety
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