Clinical agency name Agency representative name, Date of contract Nursing course name and course Number of students per clinical Clinical agency address phone number and email number unit per day Unit name type of clinical experiences Total Hours in direct client care obtained per day Accrediting body; date and results of Date last used for Indicate preceptor experiences most recent accreditation visit student with * experiences Example: Mary Lou Who 3/10/2010- Medical Surgical I, NURS 122 6 students per day/8 hrs 1.The Best Hospital, 331-111-1111 3/10/2015 Medical surgical nursing care 1010 Wonder Way, Richmond, VA mlw@Bestplace. 12 students per term/80 clinical 4 South hours direct care TJC 2014/good standing met all standards 1. 2 3. 4. 5.
Clinical agency name Clinical agency address Unit name Agency representative name, phone number and email Date of contract Nursing course name and course number type of clinical experiences obtained Number of students per clinical unit per day Total Hours in direct client care per day Indicate preceptor experiences with * Accrediting body; date and results of most recent accreditation visit Date last used for student experiences Example: 1.The Best Hospital, 1010 Wonder Way, Richmond, VA 4 South Mary Lou Who 331-111-1111 mlw@Bestplace. 3/10/2010- 3/10/2015 Medical Surgical I, NURS 122 Medical surgical nursing care 6 students per day/8 hrs 12 students per term/80 clinical hours direct care TJC 2014/good standing met all standards 1. 2 3. 4. 5.