Graduate Clinical Placement Requests
If you are a Director of Clinical Education for a graduate program or a Graduate Student looking to set up a clinical rotation, please fill out the form below to connect with our Quality Control Manager. We welcome the opportunity to collaborate and support your program’s educational goals.
1. School Information
Please provide the requested information about yourself (as the student or the DCCE)
Name
*
First Name
Last Name
Title
*
University/College Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
2. Program Type
Program types for this placement request (select all that apply):
*
Doctor of Physical Therapy (DPT)
Doctor of Occupational Therapy (OTD)
Master of Speech-Language Pathology (MSLP)
Clinical Fellowship (CCC-SLP)
Other
If selected "Other", please describe here:
3. Student Information
Number of Students Included in Placement Request:
*
Please Select
1
2
Student Name(s)
Student Year in Program
*
example: 2nd year DPT, year 3 OTD student
4. Placement Type
DPT Programs ONLY:
Clinical Experience 1
Clinical Experience 2
Clinical Experience 3
Clinical Experience 4
Clinical Experience 5
Other
If "Other", please describe:
Required Weeks or Hours?
Preferred Clinical Focus/Population (optional, select all that apply):
Orthopedics
Neurologic
Amputee
Pediatrics
General/No Preference
Aquatic Therapy
Dynamic Movement Intervention (DMI)
Pediatric Pelvic Floor
OTD Programs ONLY
Level I Fieldwork
Level II Fieldwork
Other
If "Other", please describe:
Required Weeks or Hours?
Preferred Clinical Focus/Population (optional, select all that apply):
Orthopedics
Neurologic
Pediatrics
General/No Preference
Aquatic Therapy
Dynamic Movement Intervention (DMI)
Pediatric Pelvic Floor
Sensory Integration
Safe and Sound
MSLP Programs ONLY
Graduate Student Internship
Practicum
Other
If "Other", please describe:
Required Clock Hours & Competency Areas?
Preferred Specialty Areas (optional, select all that apply):
Language
Articulation / Phonology
AAC
Feeding
Fluency
Social / Pragmatics
Sensory Integration
CCC-SLP Programs ONLY
Full Time Clinical Fellowship
Part Time Clinical Fellowship
Supervision Requirements from University?
5. Placement Schedule
For all program types
Requests Start Date
*
-
Month
-
Day
Year
Date
Requested End Date
*
-
Month
-
Day
Year
Date
Weekly Schedule:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Flexible / To Be Determined
Number of Hours Per Week?
*
Is this student interested in pediatric, adult, or a mixed caseload?
*
Pediatric
Adult
Mixed
No Preference
Are there specific learning objectives or requirements for this placement?
*
Are there any additional details or considerations we should be aware of for this student's placement?
*
6. Requirements & Supporting Documents
Does your institution require an affiliation agreement?
*
Yes
No
If yes, please upload the agreement here:
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of
Please select all documentation your university requires students to complete before starting a clinical placement. Fusion uses this information to ensure the student meets institutional requirements and is eligible for placement.
Background Check
Immunizations
HIPAA training
CPR
Other
If "Other", please describe:
Upload Files (optional)
Browse Files
Drag and drop files here
Choose a file
e.g. student handbook, student resume, affiliation agreement template, other pertinent documents for the student's placement
Cancel
of
Certification Statement
*
I certify that I am the DCCE or authorized placement coordinator submitting this request
I certify that I am the graduate student submitting this request
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: