Group Health Cooperative Nursing Student Placement Request 2011-2012

Time Sensitive — Complete by April 15, 2011

Contact information for nursing student placement requests at your institution for academic year 2011-2012. Please complete at least one form for each class.

Please be as specific as possible to help us make better placements of your students. You may find it easier to submit more than one form per class. If you have questions, e-mail Roger Walker.

* Required fields

*Institution		*Contact Name
Phone include area code*		* Email
		Fax include area code

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

Course		Instructor phone include area code
Instructor Name		Clinical area

1.	Type of students in this course
2.	Level of students in this course
3	Start date for this student placement
4.	End date for this student placement
5.	Days of week for which you are requesting placement.
6.	If you have flexibility, other acceptable days if first choices not available.
7.	Number of hours per day or week, or a time preference.
8.	Will a faculty/instructor be on site for this course?	Yes No
9.	If you expect Group Health staff to play an active role in the student's experience, please describe.

10. Unit/Clinic: Please list each unit clinic site you are requesting for this course in the boxes below, along with the number of students per site. Click here for list of Group Health clinical sites. Please answer the following:

Number of Students per day		Unit/Clinic
Number of Students per day		Unit/Clinic
Number of Students per day		Unit/Clinic
Number of Students per day		Unit/Clinic
Number of Students per day		Unit/Clinic
Number of Students per day		Unit/Clinic
Number of Students per day		Unit/Clinic
Number of Students per day		Unit/Clinic

11. 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 GHC managers.

Thank you for completing this request. We will send responses to your placement requests in mid-June 2011. If you have questions, e-mail Roger Walker.

Revised: 01/12/2011