Clinical Placement Information Form
NURS 1911 & 1912 (2nd Semester)
Name
_______ Date Submitted
_____
Address
City/State/Zip
_____
DOB _________________ SSN # ______________________ Gordon email _________________________
(SS # will be kept secure)
Home Phone Number
_______ Cell Phone
___________
Closest Large City: ______________________________________________________________________
Indicate if you are a dorm student: _____ Yes _____ No
Do you have any special concerns related to the clinical assignment that faculty should know?
________________________________________________________________
Are you taking classes, other than nursing? YES____ NO_____
If yes, please list class and time
Are you employed at a healthcare facility? Yes ____ No ____
If yes, where? ___________________________________________________________________________
□
You cannot do clinical in the hospital you are employed unless pre-approved by the course coordinator.
□
There is always the possibility of Weekend clinical. We ask for volunteers first. If enough volunteers
are not acquired, we will assign students to fill the spots. Would you like to volunteer for Weekend
clinical if one is needed? YES
NO
□
Please note: The information above serves as a REFERENCE to the clinical manager while
assignments are being made.
Gordon State College has clinical affiliations with numerous health related facilities from Atlanta to Macon and
surrounding areas. Every attempt is made to place students close to their home or dorm address. However,
due to the number of students, spaces available, and other factors, there is NO GUARANTEE that students
will be placed in the facility nearest to them.
Students should be prepared to make personal arrangements accordingly. In addition, due to the preparation
required to place students in the various clinical sites, last minute changes, just to accommodate personal
preference, are not an option.
Revised 2/16