APPLICATION
FOR
STUDENT-INITIATED COMMUNITY SERVICE PROJECT
Name of Application:
PURPOSE OF APPLICATION PROCESS:
The purpose of this application process is to:
1. Ensure alignment of project goals with those of the School of Medicine.
2. Foster a spirit of critical service and knowledge of social justice in our students as they pursue their
education, developing their roles as citizens and professionals.
3. Ensure availability of service learning opportunities for our students.
4. Ensure adequate consistent oversight of activities to maximize benefit to those served by the project, our
community partners, and our students.
5. Minimize harm to community members who are impacted by student projects.
6. Minimize risk of liability to students and the University of Washington.
7. Provide a mechanism for UW SOM to recognize student(s) for community involvement.
When is approval required?
Approval is required for any project where a UW medical student or group of students is participating in a
community service activity in their “UW student capacity” (as opposed to their individual/personal capacity).
Project examples requiring approval include participation in diagnosis and treatment of complaints, health
education, health fairs, screening and referral services, preparing a meal at a shelter or advocacy/lobbying.
When is approval not required?
Personal volunteerism not affiliated with the UW SOM does not require this approval process. If a reasonable
person would think that a student was “representing” the UW while participating in such an activity, the student
would be considered to be acting in a UW student capacity (therefore requiring approval). If you have questions
about this, please contact the Service Learning Manager.
INSTRUCTIONS FOR COMPLETION:
1. Contact the Service Learning Manager (Kelsen Caldwell – caldweka@uw.edu) to consult about your
application process, discuss a project development timeline, and schedule a visit to the Service Learning
Advisory Committee.
2. Complete all of Section I-VI unless the instructions indicate that the information is not needed for your
project. Where text is requested, the text fields will expand to accommodate your responses.
3. When you have completed Section I-VI, follow these steps:
a. Send it to your Faculty Advisor and the Service Learning Manager for review. Integrate any
feedback.
b. Once approved by your Faculty Advisor, ask them to add their signature. Signatures can be
digital or signed by hand. Email the completed form to the Service Learning Manager at
caldweka@uw.edu.
c. Present the Application to the Service Learning Advisory Committee. If approved, you will
proceed with your project. If changes are requested, you will need to implement changes and
resubmit prior to starting your project.
4. Be sure to save a copy of the completed signed document for your records.
5. Upon request, the Service Learning Manager will provide you with a PDF of the fully-completed
application after it has gone through the approval process.
For more information, see School of Medicine Policy on Student Participation in Service Learning Activities.
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APPLICATION
FOR
STUDENT-INITIATED COMMUNITY SERVICE PROJECT
SECTION I: CONTACT INFO AND PROJECT COLLABORATORS
A.
Students(s) submitting proposal
Primary Student Contact
Name
School
Email
Phone
Other involved students
Name
School
Email
Phone
Name
School
Email
Phone
Name
School
Email
Phone
Add others as needed:
B.
Involved student groups (if applicable)
Student Group
Name
Group URL
Primary Contact
Name
Email
Is your group an officially Registered Student Organization (RSO) with the UW Student
Activities Office?
Yes
1.
No/NA
Is your group an approved student club with UW School of Medicine?
Yes
No/NA
Add information about other student groups as needed:
C.
If students from other schools are participating, please indicate below. Note that
participants from other schools are responsible for seeking any approvals required by their schools.
School of Dentistry
School of Nursing
School of Pharmacy
School of Public Health
School of Social Work
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APPLICATION
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STUDENT-INITIATED COMMUNITY SERVICE PROJECT
Other Programs
MEDEX
Medical Technology
Rehab Medicine (includes OT, PT, etc)
Health Administration
Undergraduates
Other
D.
Faculty Advisors
Name / Title
School
Email
Phone
Add others as needed:
E.
Community partners
Organization
Name
Address
City ST Zip
Primary Contact
Title
Email
Phone
Add others as needed.
F.
Will an affiliation agreement be needed? (i.e., does the project entail significant
and/or ongoing involvement with an outside entity? Need for an agreement may be determined
as part of the approval process.)
Yes
1.
No/NA
Has this been discussed with the outside entity?
Yes
2.
No/NA
Has a draft agreement been prepared?
Yes
No/NA
Comments:
SECTION II: PROJECT OVERVIEW
G.
What is the name of your project?
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APPLICATION
FOR
STUDENT-INITIATED COMMUNITY SERVICE PROJECT
H.
Abstract (Brief description of your project, including overarching mission and goals of each
involved student group; please also include information about what students will be doing).
I.
How was the need for the project determined? Please include information about who you
met with and whether a needs assessment was completed.
J.
What are the objectives of the project?
K.
Describe the target population.
L.
What is the proposed start date of your project? If your project is supposed to start within a
month, please contact the Service Learning Manager as soon as possible to see if an expedited
approval process is possible.
Single Event
Recurring
How often will your project activities take place, e.g. monthly, weekly, etc.?
M.
Please describe your plan for implementing ongoing reflection activities with participating
volunteers. Reflection activities should bridge the service with specific learning objectives that
deepen and broaden insights that are drawn from service experiences.
SECTION III: PROJECT RESOURCES
N.
What resources do you need and how will you obtain them?
1.
Equipment
Yes
No/NA
Equipment description:
2.
Supplies
Yes
No/NA
Supplies description:
3.
Volunteers (other than preceptors)
Yes
No/NA
Volunteer description:
4.
Preceptors
Yes
No/NA
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APPLICATION
FOR
STUDENT-INITIATED COMMUNITY SERVICE PROJECT
5.
O.
Other
Is funding required?
Yes (please indicate funding source):
No/NA
SECTION IV: PROJECT MANAGEMENT AND LEADERSHIP
Section Recommendation: Turning subsections in Section IV into separate job descriptions for
faculty advisors, student leaders, and student volunteers will help you transition project leadership and
maintain institutional memory in the long run.
P.
Describe the faculty roles and job description for your project.
Q.
Student Leadership Roles and Responsibilities
R.
Student Volunteer Roles and Responsibilities



This section should include what exactly students of different levels of training will be doing—
e.g. MS3s/MS4s will be paired with MS1s/MS2s for blood glucose testing etc.
There can be multiple roles and corresponding responsibilities—e.g. referral coordinator, clinic
manager, volunteer coordinator, health educator. Please outline as many as are necessary for
your project to be functional.
If the project is interprofessional, please include information about how the division of labor
will be broken down by school/program/level of student training.
S.
How will student leadership and volunteers be recruited and trained (including by whom,
how often and with what materials)?

Please be specific here. If your project will include blood glucose testing, make sure
you outline how you know students will be proficient to administer blood glucose
testing.
T.
For reoccurring projects, how will student leadership be transitioned and sustained?
(Please include a timeline for leadership transitions.)
SECTION V: SUPERVISION, OVERSIGHT, AND FOLLOW UP CARE
U.
Does your project involve any of the following activities?
Providing medical care
Health screening
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APPLICATION
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STUDENT-INITIATED COMMUNITY SERVICE PROJECT
Health education

If your project does NOT involve any of the above (providing medical care, health screening or health
education), please skip to SECTION VI.

If your project DOES involve any of the above, please fill out the rest of Section V.

If you have questions regarding what constitutes the above activities or why more information is
required for projects that involve them, please refer to the School of Medicine Policy on Student
Participation in Service Learning Activities or contact the Service Learning Manager, Kelsen Caldwell,
caldweka@uw.edu.
NOTE: Preceptors are required if your project involves any student activities that constitute the practice
of medicine (see School of Medicine Policy on Student Participation in Service Learning Activities). If
applicable, provide the following information about preceptors:
a)
How many preceptors are required for the scope of the project?
(1)
b)
How did you determine this number?
Do you have commitments from the required number of preceptors?
Yes (explain below)
No/NA
Comments:
c)
Name
Information about proposed preceptors:
Specialty
Faculty status (full-time faculty
[0.5+ FTE], part-time faculty,
or community volunteer
1.
2.
3.
Add others as needed.
V.
If your project requires MD preceptors, please describe their specific roles and duties.
W.
If your project is interprofessional, please describe the specific roles and duties of non-MD
preceptors or supervisors.
X.
How will preceptors/supervisors be recruited and trained (including by whom, how often
and using what materials)?
Y.
Will your project require patient-related documentation?
Yes
No/NA
If yes, please describe in detail your plan for managing patient documentation.
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APPLICATION
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STUDENT-INITIATED COMMUNITY SERVICE PROJECT
If applicable, please describe the project’s referral and patient navigation system to
ensure patient access to necessary follow-up care.
Z.
AA. Does your project involve health education activities?
Yes
No/NA
If yes, please generally describe your plan for developing and vetting health education materials
and curriculum that are geared toward your target population.
BB.
Will your project involve interaction with people who have limited English proficiency?
Yes
No/NA
If yes, please generally describe your plan for providing quality written and spoken translation
services.
SECTION VI: DOCUMENTATION AND EVALUATION
CC. What is your plan for data collection? (At minimum, each project should be tracking number
of students involved, number of people served, and number of hours of service).
DD. What is your plan for program evaluation? (In other words, how will you know your project
is doing what it is supposed to be doing? How do you plan to improve our program over time?)
SECTION VII: TO BE COMPLETED BY FACULTY ADVISOR
Signature from a willing and qualified faculty advisor is required to ensure that the faculty advisor is committed
to this project.
Faculty advisor agrees to the following responsibilities in overseeing this student project:

Ensures that the skill sets (and licensure as applicable) of preceptors and (other) volunteers are
commensurate with the tasks and roles of the project.

Oversees the training and orientation processes for preceptors and (other) volunteers.

Oversees the documentation and evaluation processes for the project.
I AGREE TO THE ABOVE RESPONSIBILITIES AS THE FACULTY ADVISOR.
Signature (Digital or Handwritten)
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APPLICATION
FOR
STUDENT-INITIATED COMMUNITY SERVICE PROJECT
Printed Name (for digital or handwritten signature):
Date (for digital or
handwritten signature)
SECTION VIII: TO BE COMPLETED BY DEAN OF STUDENT AFFAIRS
I APPROVE THIS PROJECT.
Date (for digital or
handwritten signature):
Signature (Digital or Handwritten)
Anne Eacker, M.D.
Associate Dean for Student Affairs
SECTION IX: TO BE COMPLETED BY SERVICE LEARNING MANAGER
Sites of Practice Required
VRP Application Required
Affiliation Agreement Required
Student/s is/are in good standing
Copy of proposal forwarded to Office of Risk Management
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