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Placement Request

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RN Nursing Pin

Baccalaureate of Science in Nursing: Clinical Placement Request

This form is to indicate you are choosing the project option, to indicate you will make your own clinical arrangement, and to request placement in a hospital listed here for which we currently have an Affiliation Agreement on file. Please fill out the form completely before submitting it.

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

Clinical Placement Request
Indicate Clinical Placement or
Project Option:
(N327 requires a Clinical)
Indicate Southeast Idaho Facility or
Other Facility:
(Leave blank if Project)
Hospital Name:
(Leave blank if Project)
Affiliated Facility, or a Preceptorship Agreement:
(Leave blank if Project)
Course requiring the clinical hours (one per request):
Semester needed (i.e. Fall 2011):

Desired or required unit of clinical rotation and how many hours needed per unit:



Scheduling needs and availability (try to be as flexible as possible):