Graduate Student Non-Clinical Placement Request

Graduate Student Non-Clinical Placement Request

Do not complete this form if you are requesting a Clinical Graduate Placement
Application Form
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email Address *
Name of Nursing School *
Name Faculty Contact *

First Name Last Name
Faculty Contact Phone Number *

Area Code Phone Number
Faculty Contact Email Address *
Type of placement requested *
Program of Study *
Specific Area of Study *
Area of placement requested *
Indicate placement reason *
Specific Area of Study *
Start Date for Non-Clinical Placement *

Month Day Year
Date
End Date for Non-Clinical Placement *

Month Day Year
Date
How many hours are you required to complete *
Are you a Children's National Employee
Were you a previous Children's National Employee
Current and previous employees, please provide Employee ID#
Do you need dual access in CERNER for this placement. Please note that you can't document any care you provide as student under your Children's National employee role. If you need to document in the medical record you will need dual access.
Signature *

Clear
Please complete the follow requirements if you are not a Children's National Employee.
I First Name Last Name am not an employee of Children's National Hospital. I have understand that it is my responsibility to protect all private health information. I understand that if it is found at anytime related to my activities that I have inappropriately shared or used the information about patients (written, verbal or photo) of Children's National Hospital that my placement may be terminated.
Signature
Documentation Requirements

Nursing Student Affiliate Requirements:

https://childrensnational.org/careers-and-training/nursing/our-nursing-programs/nursing-schools-placement-request
Submit evidence of up-to-date Immunization Record

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Cancel of
Submit evidence of Background and Sex Offenders Screening

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Cancel of
Submit evidence of BLS certification

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Cancel of
Should be Empty: