Student Experience Inquiry Form

Thank you for your interest in a student experience at GHC-SCW! We require that students be 18 years or older and have already completed at least a high school degree or the equivalent.

You can expect a response within 2 weeks after submission.
Your role:*

I am student seeking a clinical rotation or other learning experience at GHC-SCWI am a program representative seeking placement for one or more studentsI am a GHC-SCW employee who is willing to serve as a preceptor for a specific studentI am a GHC-SCW manager who has approved a specific student
Do you have your Manager or Clinic Medical Director's approval to accept a student?*

YesNo
Your Name*

First NameLast Name
Your Email*
example@example.com
What level of learning experience is being requested for this student?*

Level I = shadowing only, less than 20 hours totalLevel II = supervising provider observes all activities (Examples - medical student rotations, PA or NP students, in-process PT students, graduate level behavioral health provider)Level III = able to see patients independently with less supervision needed, longer term rotation (Examples - continuity clinic resident, behavioral health intern, advanced level PT/OT student)Not sureOther
In which department are you requesting a student experience?*

Primary Care PediatricsPrimary Care Internal MedicinePrimary Care Family MedicineUrgent CarePhysical or Occupational TherapyBehavioral HealthMedical ImagingOptometry TechnicianOther
Student's Name*

First NameLast Name
Student's Pronouns*

They/Them/TheirsShe/Her/HersHe/Him/HisUnknown
Student's Email*
example@example.com
Student's Phone Number*
Please enter a valid phone number.
Is the student older than 18 years old with a completed high school degree (or equivalent degree)?*

YesNo
Student's School*
Program Student is Enrolled In*
Estimated Start Date*

MonthDayYear
Date
Estimated End Date (If Available)*

MonthDayYear
Date
What are the time requirements for the requested rotation? (How many hours per week? Per semester? Length of rotation? Total hours needed?) Enter "not known" if information is unavailable.*
Has a provider at GHC-SCW already expressed a willingness to serve as a clinical preceptor, instructor or supervisor? (If you are the provider, indicate "Yes".)*

YesNoUnsure
Potential Instructor's Name and Clinic Location for the Rotation (If Known)
Does the student need to participate in an improvement project while they are at GHC-SCW?*

YesNo
Describe the needed improvement project.*
At this time, GHC-SCW does not offer learning experiences for students under 18 years old without a high school degree.
Please note: Your information will be shared with our provider group asking for a preceptor for you but there is no guarantee for placement.
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