BASIC INFO / First Name: Click here to enter text. Last Name: Click here to enter text. MI DOB:Click here to enter text.
Are you a UW Health Employee?: Yes ☐ No ☐
Mother’s Maiden Name (for computer access): Click here to enter text.
☐ Valid CPR Certification Expiration Date: Click here to enter text.
STUDENT CONTACT INFO / Phone: Click here to enter text. Email: Click here to enter text.
PROFESSION / Choose an item. Program track, i.e., FNP, DNP, etc: Click here to enter text.
SEMESTER
PRACTICUM START DATE
PRACTICUM END DATE / Please complete a separate form for each semester.
School: Choose an item. Other:Click here to enter text.
Fall: ☐ Spring: ☐Summer:☐
Clinical semester year: 1st☐ 2nd☐ 3rd☐ 4th☐
Click here to enter a date.
Click here to enter a date.
COURSE INFORMATION
COURSE / Course #: Click here to enter text.
Title: Click here to enter text.
COURSE FACULTY / Instructor Name: Click here to enter text.
Phone: Click here to enter text. Email: Click here to enter text.
PRACTICUM PLACEMENT COORDINATOR / Coordinator Name: Click here to enter text.
Phone: Click here to enter text. Email: Click here to enter text.
CLINICAL AREA(S) DESIRED / APRN: Choose an item. PA: Choose an item.
Inpatient ☐ Clinic ☐
Other/Details: Click here to enter text.
CLINICIAN DESIRED / If you have a clinician preference or contact, please list names of APRN, PA here:
Click here to enter text.
AVAILIBILITY
TOTAL HOURS (SEMESTER) / Click here to enter text.
HOURS/WK / Click here to enter text.
DAYS/WK / Click here to enter text.
COMPLETED ROTATION AT UW HEALTH IN THE PAST6 MONTHS? / Choose an item. Have you completed a clinical rotation at UW Health in the past 6 months?
If yes, what was your UW Health user ID Click here to enter text.
Choose an item. Have you completed a clinical rotation at Meriter in the past 6 months?
If yes, what was your Meriter user ID Click here to enter text.
ADDITIONAL INFORMATION / Please provide any other pertinent information about this student that may help us consider him/her for clinical placement at UW Health.
Click here to enter text
CRIMINAL BACKGROUND CHECK / ☐ Student has undergone the Wisconsin Criminal Background Check and has no adverse criminal history.
By signing below, as the school representative, you are verifying that the student has completed the WI criminal background check and has no adverse criminal history.
______
Signature of School Representative/Title Date
______
Name of School
To be completed by the UW Health Student Placement Coordinator
HEALTH REQUIREMENTS / ☐ Completion of UWMF Non-Employee Health Form/latex Screening Questionnaire☐ Valid CPR Certification: Expiration Date
Please list any chronic condition(s) that UW Health needs to accommodate: Click here to enter text.
REQUIRED DOCUMENTS / Forms need to be completed, signed and sent to UW Health
☐UWMF Electronic Health Information Form
☐UWMF Non-Employee Safety & BBP Training
Rev 01.14.16