All applications and attachments must be scanned, formatted to correct size for printing, and emailed to as 1 attachment for printing (needs to be a continuous printing feed, please do not attach documents for individual per page printing). Last Name: DOB: Last 4 Digits of SS#: First Name: Address: Externship Course: Applying for: Spring Summer Fall Course begin date: Course end date: School: ____________________________ Faculty for externship course: Expected degree: ADN BSN MSN Name: Expected date of graduation: Phone: Last semester completed? Email: Contact Are you currently a UCSD employee? Yes Information (Please – provide email and contact #) No If yes, provide: Telephone: Job title: Email: Work location(s): Nursing unit requested: (in order of preference) Have you previously participated in a UCSD rotation? Yes No 1st) 2nd) Is this your first time as an extern at UCSD? Yes No 3rd) Shifts you can work: Day Night Please check externship type below: Preferred work days Circle: Patient Care Externship: Traditional direct patient care Mon Tue Wed Thu Fri Sat Sun Quality Externship: A hybrid opportunity for students with strong communication skills, self-motivation, and a strong alliance Desired location(s): with ensuring patient experience. Extern will partner with nurse Hillcrest Thornton Will consider either leaders to engage in special projects on units across UCSD. It can combine focus on change projects, quality assurance, leadership, and patient satisfaction (not necessarily direct patient care). Will Consider Either Patient Care or Quality Externship All applicants must include copies of the following, submitted by email to Health Insurance Coverage (required): Malpractice Insurance Coverage (required): Signed Externship Contract from Nursing Program (required): School’s Reference Letter(s) (optional/but recommended): Resume (required) and Cover Sheet (optional/but recommended): Proof of Flu, TB and Tdap Vaccinations (required):
All applications and attachments must be scanned, formatted to correct size for printing, and emailed to as 1 attachment for printing (needs to be a continuous printing feed, please do not attach documents for individual per page printing). Last Name: First Name: DOB: Last 4 Digits of SS#: Address: Externship Course: Applying for: Spring Summer Fall Course begin date: Course end date: School: ____________________________ Expected degree: ADN BSN MSN Expected date of graduation: Last semester completed? Faculty for externship course: Name: Phone: Email: Contact Information – (Please provide email and contact #) Telephone: Email: Are you currently a UCSD employee? Yes No If yes, provide: Job title: Work location(s): Nursing unit requested: (in order of preference) 1st) 2nd) 3rd) Please check externship type below: Patient Care Externship: Traditional direct patient care Quality Externship: A hybrid opportunity for students with strong communication skills, self-motivation, and a strong alliance with ensuring patient experience. Extern will partner with nurse leaders to engage in special projects on units across UCSD. It can combine focus on change projects, quality assurance, leadership, and patient satisfaction (not necessarily direct patient care). Will Consider Either Patient Care or Quality Externship Have you previously participated in a UCSD rotation? Yes No Is this your first time as an extern at UCSD? Yes No Shifts you can work: Day Night Preferred work days Circle: Mon Tue Wed Thu Fri Sat Sun Desired location(s): Hillcrest Thornton Will consider either All applicants must include copies of the following, submitted by email to Health Insurance Coverage (required): Malpractice Insurance Coverage (required): Signed Externship Contract from School’s Nursing Program (required): Reference Letter(s) (optional/but recommended): Resume (required) and Cover Sheet (optional/but recommended): Proof of Flu, TB and Tdap Vaccinations (required):
STUDENT%20NURSE%20II%20EXTERN%20PROGRAM%20(3).docx