Docstoc

Clinical Placement Request Form

Document Sample
Clinical Placement Request Form Powered By Docstoc
					                                                                                                                                                                                        Alliance for Clinical Education (ACE)
                                                                                                                                                                                             CLINICAL REQUEST FORM
School, College or University __________________________________________                                                                                                                                                                                                                                                                     Page ____ of ____

Year (August 1-July 31) ______________________________________________

Clinical Agreement With (Facility Name): _________________________________

Please complete this form electronically and email to LAHstudentplacement@centura.org

                                                                                                                                                                                                                                                                                                       Shifts (Identify




                                                                                                                                                                                         Type of Unit Requested
                                                                                                                                                            Type of                                                                                                  Length of                          1st, 2nd, 3rd
       Type of Student                                                                                        Clinical Area                                Experience                                                                                                  Shift                              Choice)                                                  Request




                                                                                                                                                                                                                  Required for the
                                                                                                                                                                                                                  Total # of Hours
                                                                                                                                                           Preceptor (1:1)
                                                                                  Fundamentals




                                                                                                                                                                                                                                                                                                                                                       Std # Granted

                                                                                                                                                                                                                                                                                                                                                                       Unit Granted
                                                                                                                                                                                                                                                                                         Combination
                         ADN 2nd yr




                                                                                                               Ned-Surg II
                                                                                                 Med-Surg I
            ADN 1st yr




                                                                                                                                                                                                                                                                                                              Evenings




                                                                                                                                                                                                                                                                                                                                                                                               Changed
                                                                                                                                                                                                                                                                              12 hours
                                                                                                                                                                                                                  Rotation
                                                                      Course
                                                 BSN Sr.




                                                                                                                                                                                                                                                                                                                                             Granted
                                       BSN Jr.




                                                                                                                                                                                                                                                                                                                                  Flexible
                                                                                                                                                                                                                                                                    8 hours
                                                           Other *




                                                                                                                                                 Other *




                                                                                                                                                                                                                                                                                                                                                                                      Denied
                                                                                                                                                                                                                                                                                                                         Nights
                                                                                                                                                                                Group
                                                                                                                                         Psych


                                                                     Prefix and                                                                                                                                                      Days of                                                                                                                                                             Comments/Additional
                                                                                                                                  Peds




                                                                                                                                                                                                                                                                                                       Days
CNA
      LPN




                                                                                                                             OB




                                                                      Number                                                                                                                                                          Week       Dates   Holidays                                                                                                                                           Information




* Please specify: Other Type of Student: ____________________                                                                                                                Other Clinical Area _____________________


            FOR SCHOOL: __________________________________________                                                                                                                                                                             FOR FACILITY: __________________________________________
                            Signature/Date                                                                                                                                                                                                                       Signature/Date

            Name Printed ____________________________________________                                                                                                                                                                          Name Printed ____________________________________________
            Title: ___________________________________________________                                                                                                                                                                         Title: ___________________________________________________
            Phone ________________________ Fax ______________________                                                                                                                                                                          Phone ________________________ Fax ______________________

            Email Address ___________________________________________                                                                                                                                                                          Email Address ___________________________________________

                                      E-ACE Clinical Request Form - Adopted 1/23/06

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:10/20/2011
language:English
pages:1