Clinical Agency Roster Clinical Agency Name and address Agency Contact phone number and Date of Contract Nursing course name/number and type of Number of students per clinical unit per Unit name email (person that will be able to clinical experiences obtained day/ hrs on unit provide information regarding the Total number of students per term/ student and faculty performance on the Total Hours in direct client / Accrediting Body; date and results of most recent unit) Indicate preceptor experiences with * accreditation Example: Unit: Mary Lou Who 3/10/2010- 3/10/2015 Medical Surgical I, NURS 122 6 students per day/8 hr The Best Hospital 4 south 331-111-1111 Medical surgical nursing care 1414 Oak Lane mlw@Bestplace. 12 students per term/80 clinical hours Richmond, VA direct care TJC 2014/good standing met all standards 1. 2. 3. 4. 5. 6.
Clinical Agency Roster Clinical Agency Name and address Unit name Agency Contact phone number and email (person that will be able to provide information regarding the student and faculty performance on the unit) Date of Contract Nursing course name/number and type of clinical experiences obtained Number of students per clinical unit per day/ hrs on unit Total number of students per term/ Total Hours in direct client / Indicate preceptor experiences with * Accrediting Body; date and results of most recent accreditation Example: The Best Hospital 1414 Oak Lane Richmond, VA Unit: 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 hr 12 students per term/80 clinical hours direct care TJC 2014/good standing met all standards 1. 2. 3. 4. 5. 6.
Application_Nursing_Education_Program.docx