Clinical Request for Nursing Students

Program:

Semester:

Semester Year:

Instructor:

Clinical Instructor (if different from instructor):

Work Phone:

Cell Phone:

Email:

Start:

End:

Clinical Days of the Week

Time of Day:

Number of Students

Unit Request:

ICU

MedSurg

L&D

Nursery

Surgery

Potential Dates Available for Computer Class

^{**You will receive an email in reference to your request.}