Student Name (full name):
Student Email:
Program of Study:
(BSN/MSN/ Ph.D/ DNP)
Institution Name:
Faculty Advisor:
Faculty Advisor’s Email:
Preceptorship Role: ☐ Nurse Practitioner
☐ Physician’s Assistant
☐ Nursing Leadership
☐ Nursing Education
☐ Nursing Informatics
☐ Other Clinical Role Please Specify: ______
Hospital of Interest: ☐ Monroe Carell Jr. Children’s Hospital at Vanderbilt
☐ Vanderbilt University Medical Center (Adult Hospital)
☐ Vanderbilt Medical Group (VMG - Outpatient)
Area of interest:Dates of Preceptorship:
# of hours to complete:
Please write a statement regarding your goals or objectives for this experience:
Name of Preceptor:
Email of Preceptor:
Phone Number of Preceptor:
Additional Information:
The Student Placement program at Vanderbilt University Medical Center (VUMC) allows graduate students an opportunity to complete clinical rotations where there are available preceptors.
The following items are required to set up a clinical rotation:
· The student’s school must have a current Affiliation Agreement with VUMC.
· This request form and the Informational Grid (submitted by your school leadership to verify additional requirements) must be sent to 10 business days prior to the clinical rotation begin date.
· Completion of the Vanderbilt Orientation Module and Quiz is required before beginning the rotation. Once completed, the online quiz should be given to the faculty advisor for review and placed in the student’s file.
· The online confidentiality agreement found at the end of the Orientation Module/Quiz is required to be completed and given to the faculty advisor to place in the student file.
· Once the above documents have been received by Student Placement, we will begin to work on obtaining badge and computer access (if needed).
· All students (even VUMC employees) will be required to obtain a Visiting Student ID badge to wear while on campus for their clinical rotation.
· Once an ID badge is obtained, students should visit the Parking Office to obtain a parking pass for the duration of their rotation.
After the requirements are completed, the student will receive a confirmation email. The student can then email the VUMC preceptor to confirm dates for the clinical rotation schedule. Upon completion of the rotation, the student ID badge is left in the clinical area to be shredded.