Request for Use of New Clinical Site

Request for Use of New Clinical Site

Undergraduate Studies

Request for Use of New Clinical Site

Contact information:

Name of person making the request:Click here to enter text.

Phone: Click here to enter text.Pager: Click here to enter text.Other: Click here to enter text.

Date of request:Click here to enter text.

Date student placementto begin:Click here to enter text.

Course for which the clinical request is being made:Click here to enter text.

Course coordinator:Click here to enter text.

Clinical Site/Agency Name:Click here to enter text.

Unit(s) within the Site/Agency requested:Click here to enter text.

Contact information for the agency:

Name of person(s) with whom you talked:Click here to enter text.

Click here to enter text.

Title(s):Click here to enter text.

Address of agency:Click here to enter text.

City:Click here to enter text. St:Click here to enter text. ZipClick here to enter text.

Phone: Click here to enter text.Fax: Click here to enter text.Email: Click here to enter text.

Are there any agencies that this agency may work with that would also need a contract?

___ Yes___ NO

If Yes, please list the names and contact information:

Click here to enter text.

Click here to enter text.

Click here to enter text.

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Briefly describe your interaction with the agency about student placement at the site.

Click here to enter text.

Click here to enter text.

Click here to enter text.

Briefly describe how you wish to use the site for student learning:

Click here to enter text.

Click here to enter text.

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Will student clinical type be traditional (on-site clinical faculty providing supervision), precepted (agency staff as clinical teachers), or observational (combined faculty-agency supervision)?

Click here to enter text.

How long will the experience last for each student (e.g. few hours, one day, several days or weeks, etc.)?

Click here to enter text.

How many students will be at the site each day? Click here to enter text.

Additional Information for Undergraduate Studies Office to obtain:

CEO, full contact information:

Name:Click here to enter text.

Address1:Click here to enter text.

Address2: Click here to enter text.

City:Click here to enter text.ST:Click here to enter text.Zipcode:Click here to enter text.

Email Address: Click here to enter text.

Other SON’s using the site? ___ Yes___ NO

If YES, who and how?

Click here to enter text.

Click here to enter text.

Click here to enter text.

NC BON Notified? Click here to enter text.YesClick here to enter text.NO

Current contract with the SON? Click here to enter text.YesClick here to enter text.NO

Other notes during phone contact(s):

Click here to enter text.

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Click here to enter text.

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Revised 1/27/12

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