STUDENT/CLINICAL ROTATION INFO First Name: Last Name: DOB: BASIC INFO Are you a UW Health Employee?: Yes No Mother’s Maiden Name (for computer access): Valid CPR Certification Expiration Date: STUDENT CONTACT INFO Email: Program track, i.e., FNP, DNP, etc: PROFESSION Please complete a separate form for each semester. SEMESTER School: Other: Fall: Spring: Summer: Clinical semester year: 1st 2nd 3rd 4th PRACTICUM START DATE PRACTICUM END DATE COURSE INFORMATION Course #: COURSE Title: Instructor Name: COURSE FACULTY Phone: Email: Coordinator Name: PRACTICUM PLACEMENT Phone: Email: COORDINATOR APRN: PA: CLINICAL AREA(S) DESIRED Inpatient Clinic Other/Details: If you have a clinician preference or contact, please list names of APRN, PA here: CLINICIAN DESIRED AVAILIBILITY TOTAL HOURS (SEMESTER) HOURS/WK DAYS/WK COMPLETED ROTATION AT UW HEALTH IN THE Have you completed a clinical rotation at UW Health in the past 6 months? PAST 6 MONTHS? If yes, what was your UW Health user ID Have you completed a clinical rotation at Meriter in the past 6 months? If yes, what was your Meriter user ID
STUDENT/CLINICAL ROTATION INFO BASIC INFO First Name: Last Name: DOB: Are you a UW Health Employee?: Yes No Mother’s Maiden Name (for computer access): Valid CPR Certification Expiration Date: STUDENT CONTACT INFO Email: PROFESSION Program track, i.e., FNP, DNP, etc: SEMESTER PRACTICUM START DATE PRACTICUM END DATE Please complete a separate form for each semester. School: Other: Fall: Spring: Summer: Clinical semester year: 1st 2nd 3rd 4th COURSE INFORMATION COURSE Course #: Title: COURSE FACULTY Instructor Name: Phone: Email: PRACTICUM PLACEMENT COORDINATOR Coordinator Name: Phone: Email: CLINICAL AREA(S) DESIRED APRN: PA: Inpatient Clinic Other/Details: CLINICIAN DESIRED If you have a clinician preference or contact, please list names of APRN, PA here: AVAILIBILITY TOTAL HOURS (SEMESTER) HOURS/WK DAYS/WK COMPLETED ROTATION AT UW HEALTH IN THE PAST 6 MONTHS? Have you completed a clinical rotation at UW Health in the past 6 months? If yes, what was your UW Health user ID Have you completed a clinical rotation at Meriter in the past 6 months? If yes, what was your Meriter user ID
APP_student_placement_request.docx