ACTION PLAN
Student _____________________________________________________________
Clinical Site__________________________________________________________
CI__________________________________________________________________
Semester/Year_________________________________________________________
Problems Identified on the CPI
Objectives which must be met for successful completion of the clinical course:
Plan and Timeline to Meet the Objectives:
___________________________________ _________________________________
Clinical Instructor
Date
NU Faculty Member
Date
____ I agree to the plan and terms as outlined and understand that I am at risk for not
passing this clinical course if I do not meet the established objectives.
____ I do not agree to the terms as outlined. I understand that my failure to accept and
follow this plan may decrease my chance of successful completion. My rebuttal to
this action plan is attached.
___________________________________________
Student
Date