Placement Request

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RN Nursing Pin

Baccalaureate of Science in Nursing: Clinical Placement Request

This form is to indicate for each of the NURS courses with a clinical component (NURS 327, NURS 400, NURS 449 and NURS 450) whether you are choosing:

  • the project option,
  • the LSEI "local" option,
  • the Preceptorship Agreement,
  • or requesting placement in a hospital listed here for which we currently have an Affiliation Agreement on file. The clinical request deadlines for affiliated facilities with BYU-Idaho are the following:
    • Fall - May 1st
    • Winter - September 30th
    • Spring - December 15th

All other requests (Preceptorship, Project, LSEI "local") are due

one week prior to the start of the semester.

Please fill out the form completely before submitting it. If you have any questions, please call the Nursing Outreach office at (208) 496-1281.

Your Information
Name:
BYU-I E-mail:
I-Number:
Current RN Employer:
Employed there since what date:

Clinical Completion Plan/Placement Request
Indicate "Clinical Placement" or
"Project Option":
(N327 requires a Clinical)
Indicate "Southeast Idaho Facility" or
"Other Facility":
(Leave blank if Project)
Hospital, Clinical or Facility Name:
(Leave blank if Project)
Affiliated Facility, or a Preceptorship Agreement:
(Leave blank if Project)
Course requiring the clinical hours (one course per request):
Semester needed (i.e. Fall 2014):

Indicate the desired/required unit for clinical rotation and how many hours needed per unit. (Leave blank for project.):



Indicate your scheduling needs and availability. (Try to be as flexible as possible. Leave blank for project.):