Application for Graduate Placement
Barnabas Health
Newark Beth Israel Medical Center – Nursing Education
Name of Hospital receiving request: ______
Date request received: ______
Person completing application: ______
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Request Information:
Student’s Name: ______
Graduate School: ______
Address of School: ______
Graduate Advisor: ______
Phone numbers: School contact: ______
Student contact: ______
E-Mail: ______
Expected date of degree completion: ______
Description of Graduate Degree sought:
(e.g. MSN in critical care; Clinical Specialist – critical care, etc.
Be specific: ______
Course Title and Number: ______
Description of the Placement Requested:
(Type of unit, type of experiences sought, type of patient interactions needed, committee or administrative interactions, etc.):
______
______
______
______
Specific projects required for the course R/T to placement:
(e.g. case study, oral presentation, reports, patient interviews, chart reviews, etc.)
______
______
Qualifications and Experience of the Preceptor/Mentor:
______
Number of weeks for placement: ______
Number of hours per week: ______
Days of week available for placement: ______
Start date: ______End date: ______
Additional scheduling limitations if any: ______
Does placement continue for more than one semester? Yes _____ No _____
If yes, how many semesters? ______
Requirements of the Preceptor/Mentor:
(e.g. student evaluations, meetings with student, meetings with faculty, summary reports etc.)
______
______
Directions:
The following must be verified prior to the student beginning the clinical experience. This form is then returned to Nursing Education.
Exp Date / Verified By:Proof of professional malpractice insurance verified?
11/03; 5/09; 8/10; 06/13; 8/13
LWB
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Response to Placement Request:
______Placement Accepted
______Placement Not Accepted
G:\AFFILIATE SCHOOLS\2014\2014 FORMS\Application for Graduate Placement August 2013.doc