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Preceptor Request Application Form

Preceptor Request Application Form - AREA Medical-Surgical...

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VENTURA COLLEGE NS40B Preceptorship Request Application To help place students and to give students the opportunity to state preferences, we need the following information from you. Please list your 1 st , 2 nd , 3 rd preferences and list any other request. Every effort will be made to meet your request; however, that may not be possible due to the limited placements and shifts. Student Name __________________________Telephone No. ____________________ Address ______________________________________________________________ Email address _________________________________________________________ HOSPITALS: SJRMC 1 st Choice ______________________________________ CMH Ojai 2nd Choice_____________________________________ SJ Pleasant Valley Santa Paula 3 rd Choice _____________________________________ VCMC CLINICAL SHIFTS: Day 7a-7p 1 st Choice ________________________ Nights 7p-7a 2 nd Choice _______________________ Other ____________ 3 rd Choice _______________________
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Unformatted text preview: ____________________________________________________________________ AREA Medical-Surgical Labor & Delivery 1 st Choice ______________ Telemetry Post Partum Peds ICU 2 nd Choice______________ Psych (Hillmont) Nursery ER OR 3 rd Choice______________ CCU NICU ___________________________________________________________________ Which is more important (Check one) _____________Hospital __________ Hours ______________ Specialty Area IF YOU WORK AT ANY OF THE ABOVE CLINICAL FACILITIES, PLEASE COMPLETE : Hospital:_______________ Unit________ Shift: __________ Job Title______________ If you are requesting a specialty area, please justify why you are qualified to go into this area: _____________________________________________________________________________ _______________________________________________________________ Student Signature_______________________________ Date _____________...
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  • Fall '11
  • MaryZacharias
  • specialty area, Ventura County, California, Ventura, California, Choice _______________________, NS40B Preceptorship Request

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