Clinical Request Information Form
NURS 2910 & 2911 (3 rd Semester)
Name ______________________________________________________________________
Address
City/State/Zip
DOB ________________ SSN # ______________________ Gordon Email ___________________
(SS # will be kept secure)
Home Phone Number Cell Phone
While we have the utmost respect for our part-time clinical instructors, we desire for every student to have the opportunity to be placed with a full-time faculty member for a clinical experience. Have you been assigned to a full-time faculty member during your clinical experience?
If yes, which semester? 1 st Semester Faculty Name:
2 nd Semester (Med-Surg) Faculty Name:
2 nd Semester (Mental Health) Faculty Name:
Do you have any special concerns related to the clinical assignment that faculty should know?
________________________________________________________________________________
Are you taking other classes? YES NO
If yes, please list class and time
Are you employed with a healthcare facility? 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 a Weekend clinical. We ask for volunteers first. If enough volunteers are not acquired, we will randomly 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 coordinator while assignments are being made.
Gordon State College has clinical affiliations with numerous health related facilities from Atlanta to
Macon. 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, last minute changes, just to accommodate personal preference, are not an option.
Revised 2/16