application questionaire

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Indiana University Health
Bloomington
STUDENT PLACEMENT
APPLICATION
SPRING 2013 SEMESTER
Human Resources
Bloomington, Indiana
NAME (Last, First, Middle):
Current Address:
City:
State:
Zip:
City:
State:
Zip:
Phone Number:
E-Mail Address:
Permanent Address:
Female
Male
High School / University / Program:
Please check this box if you are under the age of 18
Please check one:
Internship
Shadowing
Note: An internship is for college students who want more than 25 hours of experience. If you want less than 25
hours and/or you are a high school student, please check the shadowing box.
PLEASE NOTE BEFORE CONTINUING:


For students interested in interning or shadowing with a Physician or Nurse Practitioner: You must
first directly schedule your internship or shadowing experience with the Physician and/or Nurse
Practitioner. Do not continue with this application until you have direct approval from the Physician
or Nurse Practitioner.
For students interested in a nurse internship: This internship is offered in the summer for nursing
students who meet certain requirements. For more information, please look for this internship
positing on our website in February under the “careers” link.
Please check any applicable boxes below denoting why the experience is needed (This is
required in order to assist us with your placement). NOTE: Students who are required to complete
an internship related to a degree or class requirement will be given priority over those requesting a
personal experience.
Pre-requisite for application to a degree program {Need experience to be considered for program
and will not be sponsored by school (i.e. Physical or Occupational Therapy & Health
Administration programs)}. This does not include Nursing. Please attach resume to show
extracurricular activities and work experience.
Required experience for current class or program (Already enrolled in class/program and need
experience as completion or requirement). Please attach resume to show extracurricular
activities and work experience.
Personal experience not related to school requirements. Please attach resume to show
extracurricular activities and work experience.
Indiana University Health
Bloomington
Human Resources
Bloomington, Indiana
STUDENT PLACEMENT
APPLICATION
SPRING 2013 SEMESTER
APPLICATION QUESTIONAIRE
Please answer ALL questions below completely and
in as much detail as possible.
Registered Nurse
1. Please choose one profession from
this list.
Physical Therapist
Medical Lab Tech
Occupational Therapist
Medical Technologist
Speech Therapist
Pharmacist
Radiology Tech
Paramedic
Radiation Therapist
EMT
Respiratory Therapist
Administrative
Surgical Technologist
Public Health
2. Describe your interest in the area you
have chosen to explore. (Please
elaborate so that we may find your
placement to the best of our ability.)
3. Please explain specific length of
request. (Example: “I need/would like
to complete 8 hours before 5/20/13”)
4. Please give very specific details of your
availability (dates and times) during the
Spring 2013 Semester. Consider class
& work schedules, exams, etc.
(Example: I am available on Tuesdays
& Thursdays 9a – 11a, Mondays after
5p, & Saturdays 8a – 12p.)
5. Have you ever been convicted or pled
guilty to a violation of any law?
Histology Tech
Yes
No
Professional
Social Worker
Indiana University Health
Bloomington
STUDENT PLACEMENT
APPLICATION
SPRING 2013 SEMESTER
Human Resources
Bloomington, Indiana
APPLICATION QUESTIONAIRE
Please answer ALL questions below completely and
in as much detail as possible.
6. If the answer to question #5 is yes, list
the violation and date of conviction or
plea and explanation.
All Shadowing and Internship applicants must sign and date below (Please read carefully
before signing):
I have read and understand the Application Information & Instructions section and have completed the
Student Placement Application to the best of my ability. I voluntarily authorize Indiana University Health
Bloomington to make a thorough investigation of my eligibility for a shadowing experience or internship. I
agree to meet all immunization requirements before beginning my student experience. I understand that
my experience may be terminated for any misinformation, omission of facts appearing on the application
form, or for any violation of rules or regulations.
Electronic Signature:
Date:
** Please submit completed application via e-mail to: [email protected]
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