Table 1 Clinical Agencies Roster List all agencies used for clinical learning experiences (Include additional sheet, if necessary) 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 Indicate preceptor experiences most recent accreditation or approval to for student with * operate visit experiences Example: Mary Lou Who 3/10/2010- Medical Surgical I, NURS 122 6 students per day/8 hrs 1.The Best Hospital, 4 South 331-111-1111 3/10/2015 Medical surgical nursing care 1010 Wonder Way, Richmond, VA mlw@Bestplace. 12 students per term/80 clinical direct care per student TJC 2014/good standing met all standards hours’ 1. 2. 3. 4. 5.
Table 1 Clinical Agencies Roster List all agencies used for clinical learning experiences (Include additional sheet, if necessary) 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 or approval to operate visit Date last used for student experiences Example: 1.The Best Hospital, 4 South 1010 Wonder Way, Richmond, VA 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 per student TJC 2014/good standing met all standards 1. 2. 3. 4. 5.
Survey_Visit_Report_Form.docx