NIHT Clinical Site Request & Approval Form

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:

Type a question
Clinical Site Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinical Site Phone Number

Area CodePhone Number
Clinical Site Email Address
example@example.com
Type of Clinical Facilicy

SECTION 3: CLINICAL SUPERVISOR / PRECEPTOR INFORMATION
Clinical Supervisor Full Name
Supervisor Title
Supervisor Credentials

Other
Supervisor Email Address
example@example.com
Supervisor Phone Number

Area CodePhone Number

SECTION 4: CLINICAL PRACTICE DETAILS
Anticipated Clinical Start Date

MonthDayYear
Date
Anticipated Clinical Completion Date

MonthDayYear
Date
Types of Studies Available at This Site

SECTION 5: REQUIRED ACKNOWLEDGMENTS
Clinical Placement Acknowledgment

SECTION 6: ELECTRONIC SIGNATURE
Student Electronic Signature
Date

MonthDayYear
Date
Should be Empty: