NIHT Clinical Site Request & Approval Form

NIHT Clinical Site Request & Approval Form
This form is required for students who have elected to complete their 20 required clinical practice hours at a clinical site in their home state.

Clinical hours may not begin until the proposed clinical site has been reviewed and approved by the National Institute for Health Technology (NIHT).

Incomplete forms or missing information may delay approval.
SECTION 1: STUDENT INFORMATION
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Cohort:

SECTION 4: CLINICAL PRACTICE DETAILS
Anticipated Clinical Start Date

MonthDayYear
Date
Anticipated Clinical Completion Date

MonthDayYear
Date
Types of Studies Available at This Site

Diagnostic PSGSplit-Night StudyCPAP / BiPAP TitrationMSLT / MWTHSATScoring Observation

SECTION 5: REQUIRED ACKNOWLEDGMENTS
Clinical Placement Acknowledgment

I understand that clinical hours may not begin until this site is formally approved by NIHT.I understand that completion of 20 supervised clinical hours is required for program completion.I understand that my clinical supervisor must complete and sign the NIHT Clinical Skills Checklist & Hour Verification Form at the conclusion of my clinical experience.

SECTION 1: STUDENT INFORMATION