University of California, Riverside

Future Physician Leaders Program

Future Physician Leaders Forms and Documents

Forms and Documents for FPL Participants

This page contains the forms and documents that will be used by participants in the Future Physician Leaders program. Some are general, to be used by all participants, while others are specific to the Coachella Valley, Riverside/San Bernardino and Temecula regions.

For Prospective Applicants

The FPL Frequently asked Questions is for students who are interested in applying.

The Physician Shadowing Requirements  document is for students applying to the Riverside-San Bernardino and Coachella Valley region who would like more information before applying for the shadowing component.

Short Response Questions for high school and college students are provided for students to work on before applying.

Temecula Site only:

Additional requirements is asked of students once they are accepted.

Information on Temecula shadowing requirements.

FPL Participants Social Contract

The FPL Social Contract  is signed by all participants in the Future Physician Leaders Program and serves as a commitment to participate in all aspects of the program, including the Leadership Lecture Series and the Community Service Project.

FPL Student Committee Application

The FPL Student Committee is for students interested in being mentors and leaders after the conclusion of the program

Calendar and Schedule

Coachella Valley FPL Students

Riverside/San Bernardino FPL Students

Temecula FPL Students

  • 2015 Calendar - Temecula
  • Leadership Lecture Series Schedule - Temecula

Physician Shadowing Program

These documents will be used by all FPL students participating in the Physician Shadowing Program (PSP).

Shadowing Hours Log In Sheet
Use this form to record your hours participating in the Physician Shadowing Program.

UCR SOM_HIPAA PPP Training_2014
This Powerpoint course is designed to provide students with information about their responsibilities in preserving and protecting patient, employee, research and business information. It is required by the Health Insurance Portability and Accuontability Act of 1996 (HIPAA).

UCR SOM_HIPAA Acknowledgement Form
This form must be downloaded and printed out to acknowledge the completion of the UCRSOM HIPAA Privacy and Security Training Module.

Eisenhower Consent Form - Coachella Valley
This form must be downloaded and filled out prior to participating in the Physician Shadowing Program at Eisenhower Medical Center.

Community Health Project

These documents will be used by FPL students during the Community Health Project portion of the program.

CHP Workshop Topic: Dissemination Video
This YouTube video discusses research design, data collection and presentation, and specifics of the Community Health Project.

Community Health Project Syllabus
This document contains the description and the workshop schedule of the FPL Community Health Project

Sample Poster Boards_2014
Examples of Community Health Project posters from previous years.

Reimbursement Form
This form will be used to reimburse students for the costs of the Community Health Project. A sample reimbursement form is available to demonstrate how to fill out the form properly.

W9 Form
This link will allow you to download a W9 form from the IRS website.

Elements of Informed Consent Handout
A document from Portland State University Human Subjects research Review Committee that explains the elements of informed consent.

Institutional Review Boards (IRB) Common Risks and Solutions Handout
Learn about some of the "red flags" and other easily solved problems that can result in IRB delays in projects.

Budget Justification Worksheet
This form should be used to explain and justify expenses incurred during the Community Health Project.

Campus Maps & Parking Information

CSU San Bernardino  Campus Map 

UCR Palm Desert Campus Map & Directions

UCR School of Medicine Education Building

Eisenhower Medical Center Map & Directions

More Information