Undergraduate Student Clinical Placement Request Form
Application Form
Name of Individual Submitting Request
*
First Name
Last Name
Email Address
*
Name of Nursing School
*
Name of Clinical Instructor
*
DC RN License #
*
Clinical Instructor Email Address
*
Clinical Instructor Phone #
*
# of Students (Max 5)
*
# hours per student
*
# of Clinical Groups
*
# of Weeks per Clinical Group
*
In Patient Unit Requested
7East Medical
Neuroscience
Surgical Care
4 Main
Heart & Kidney
Clinic Requested
Specialty Clinic Rotation (5 students per day)
Columbia Heights ( 2 students per day)
Montgomery County Regional Outpatient (2 students per day)
Friendship Heights Regional Outpatient Clinic (1 student per day)
Complex Care Shepard Park (4 students per day)
Start Date for Clinical Placement Request
*
-
Month
-
Day
Year
Date
End Date for Clinical Placement Request
*
-
Month
-
Day
Year
Date
Day of Week Preference
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Shift Preference
*
Day
Evening
other_______________
Fields marked with * are required
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