Nursing Student Placement Request

Please complete at least one form for each class.

*Indicates a required field

*Institution:

*Contact name:

*Phone #: (include area code)

*E-mail address:

*Re-enter e-mail address:

Fax #: (include area code)

To help us identify an appropriate clinical placement, please answer the following:

Course:

Instructor name:

Instructor phone #: (include area code)

Clinical area:

Type of students in this course:

Level of students in this course:

Start date for this student placement: MM/DD/YYYY

End date for this student placement: MM/DD/YYYY

Days of week for which you are requesting placement:

If you have flexibility, other acceptable days if first choices not available:

Number of hours per day or week, or a time preference:

Will a faculty/instructor be on site for this course? Yes No

If you expect Kaiser Permanente staff to play an active role in the student's experience, please describe:

List each unit clinic site you are requesting for this course in the boxes below, along with the number of students per site: You may check the list of Kaiser Permanente clinical sites.

Number of students per day:

Clinic:

Number of students per day:

Clinic:

Number of students per day:

Clinic:

Number of students per day:

Clinic:

Number of students per day:

Clinic:

Number of students per day:

Clinic:

Number of students per day:

Clinic:

Number of students per day:

Clinic:

Comments: It will be helpful to know if the students will rotate (and how often) or will remain the same for the entire quarter/semester. Please help us describe your requests to our Kaiser Permanente managers.