University of Maryland
School of Nursing
Request for Student Clinical Placement
Course #, Section & Title: NURS
Semester(s): Fall
Yr.
| Winter
Section Number
Yr.
Title:
| Spring
Yr.
Number of Students:
| Summer
Yr.
[To “x” a checkbox, click directly next to the checkbox you wish to appear “X’ed”. RIGHT click, then click Properties then click
Checked, then OK.]
Name and Address of Agency:
Street
Dates
City
Hours & Days
Zip
Faculty
Preceptor(s)
Chief Executive Officer for Nursing
Contact Person for Student Placement
Name:
Title:
Address:
Telephone:
Fax:
Email address:
Others in agency who should receive the information – Please keep this minimal.
(Include name and telephone numbers for key contact people.)
Is there a current contract with the clinical agency? Yes
Is this agency being used for the first time? Yes
No
Unit(s)
No
Expiration Date
Does any student have an approved request for special accommodations as required by the Americans
with Disabilities Act? Yes
No
Special accommodation(s)
Does the agency require any special tests or immunizations? If so, please check which ones.
Rubeola
Rubella
Mumps
Hepatitis B
Varicella Titre
PPD
Other requirements (Please specify):
Comments or Objectives:
The above information has been validated with the contact person for student placement in the agency.
Yes
No
__________________________________________
Course Coordinator Signature
_______________
Date
____________________
Office Phone
__________________________________________
Department Chair
_______________
Date
____________________
Office Phone
Sent to Coordinator, Legal and Contractual Services? Yes
I:/Clin/Clinical placement request form 2.doc
Rev. date: 11/20/08
BG
No