NCHD Nursing Student Request Form

  • NCHD Nursing Student Request Form

    Use this form to request a practicum, internship or other field experience with the North Central Health District. While not all questions are required, the more information we have the better we will be able to work with you. Not all requests can be honored, as staff and projects change over time. Once your request is complete, please email your resume to jessica.pearson-spikes@dph.ga.gov. Important Notice: We currently cannot accept medical assistant, lab technician, or nurse practitioner students, due to staffing.
  • Format: (000) 000-0000.

  • Academic Information

  • What degree level will this field experience be applied to? For other degrees, or if it is not directly related to a degree, please choose "Other" and explain. At this time we are unable to accommodate Nurse Practitioner (NP) Students.*

  • Field Experience Information

  • Proposed start date and end date for field experience. When would you like to start your field experience? Actual start date may change, this just gives us an idea of when you would be available.*
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  • Additional Background and Interests

    This section is used to help us determine if we can adequately assist you in your program of study and place you with a a program or project.
  • Have you used an electronic medical record system in any of your rotations?*

  • Availability

    Thinking about your schedule DURING the time you will be working on your internship: for each day indicate when you would be AVAILABLE (e.g.: 8am to 1pm) to be at your field experience. Keep in mind, most offices are open Mon-Fri 8am-5pm. If you are not available on a specific day, please list "N/A" or "Not Available". This helps us determine if your schedule with fit with the various programs. Some programs prefer students be available during specific time periods. We require all students to be available a minimum of 10 hours a week.
  • Is there a particular location that you would prefer to work? (Select all that apply) The North Central Health District covers a 13-county area in middle Georgia. Most programs are at the district office but nursing and environmental health are in each county (with some additional programs in Houston and Bibb).*
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