□ □ Name: _____ Bilingual Eng/Sp? Yes No □Phone □ □ (Home) (Cell) Email: Please fill out clearly and completely. Designate the best contact method () Select [1] □BSN □Nutrition □Other Student Student Student School/Program Affiliation: School/Program Contact: __ Phone: Email: _ _____________________ Public Health Preceptor ___Phone: __________ Or [2] □PHN Employee Supervisor: _________________________________ Website: The link below contains the most current observation schedule as well as forms, reading materials and links for more WIC Program information. In the Request Table below enter dates/sites in order of preference. All observations are 4 hours (8:00 am -12:00 pm or 1:00 pm - 5:00 pm). If your availability changes, please cancel promptly. Rescheduling is not guaranteed. The website will be updated at least weekly. REQUEST TABLE choice 1 choice 2 choice 3 choice 4 Date Site WIC Site Locations South Oxnard Public Health Center (SOX) Santa Paula Public Health Center 2500 C St., Suite A 620 W. Harvard Blvd. Oxnard, CA 93033 Santa Paula, CA 93060 North Oxnard Public Health Center (NOX) Simi Valley Public Health Center 2240 E. Gonzales Rd., Suite 170 1133B Los Angeles Ave Oxnard, CA 93036 Simi Valley, CA 93065 Ventura Public Health Center 3147 Loma Vista Rd. Ventura, CA 93003 What are your learner objectives during the WIC visit? WIC Admin only: Dear __________________________, Please report to the WIC site circled above. After your visit, have the Site Supervisor sign this form and provide you with a copy for your records. Scheduled site visit date: Scheduled time: Site Supervisor contact: Phone: WIC Site Supervisor: Signature Date
Name: _____ Bilingual Eng/Sp? □ Yes □ No □Phone (Home) □ (Cell) □ Email: Please fill out clearly and completely. Designate the best contact method () Select [1] □BSN Student □Nutrition Student □Other Student School/Program Affiliation: School/Program Contact: __ Phone: Email: _ _____________________ Public Health Preceptor ___Phone: __________ Or [2] □PHN Employee Supervisor: _________________________________ Website: The link below contains the most current observation schedule as well as forms, reading materials and links for more WIC Program information. In the Request Table below enter dates/sites in order of preference. All observations are 4 hours (8:00 am -12:00 pm or 1:00 pm - 5:00 pm). If your availability changes, please cancel promptly. Rescheduling is not guaranteed. The website will be updated at least weekly. REQUEST TABLE choice 1 choice 2 choice 3 choice 4 Date Site WIC Site Locations South Oxnard Public Health Center (SOX) 2500 C St., Suite A Oxnard, CA 93033 North Oxnard Public Health Center (NOX) 2240 E. Gonzales Rd., Suite 170 Oxnard, CA 93036 Santa Paula Public Health Center 620 W. Harvard Blvd. Santa Paula, CA 93060 Simi Valley Public Health Center 1133B Los Angeles Ave Simi Valley, CA 93065 Ventura Public Health Center 3147 Loma Vista Rd. Ventura, CA 93003 What are your learner objectives during the WIC visit? WIC Admin only: Dear __________________________, Please report to the WIC site circled above. After your visit, have the Site Supervisor sign this form and provide you with a copy for your records. Scheduled site visit date: Scheduled time: Site Supervisor contact: Phone: WIC Site Supervisor: Signature Date