Application Form - NP, CNM, DNP, MSN, SRNA and SAA Students

Visiting PA students must NOT use this application form. Visiting PA students must complete their rotation requests on the Visiting PA Rotation Request Application found on the APP Center Visiting PA student webpage.

Full LEGAL Name*

Enter your full legal name. If you do NOT have a middle name, enter n/a in the middle name field

First Middle Last

Today's Date*

Enter today's date

Student Email*

Enter your school email address

Phone Number*

Enter your phone number

University*

Enter the name of your school

Program*

Use the drop down to select the program you are enrolled in at your school

Advanced Practice Area*

Check the box to indicate your Advanced Practice Area of study. If you are dual-enrolled, select BOTH boxes to indicate both practice areas.

Is this a Post-Graduate Certificate Program?*

Answer yes if you are a MSN or DNP prepared APRN who is enrolled in a program to obtain education and training in a new population area

No
Yes

Expected Graduation Date (enter month and year)*

Enter your expected date of graduation using this format: Month and yyyy (e.g. May 2023)

Are you a UNC Health employee?*

Select yes if you are a CURRENT UNC Health employee

No
Yes

If employee, list UNC Health entity and unit/clinic

Describe where you currently work and your role. For example, I am a RN at UNCMC on L&D

UNC Health Email

List your UNC Health email address

UNC Health EMPLOYEE Epic access

List your U# and describe what EPIC access you currently have as an employee (e.g. Inpatient Nurse). The APP Center will need to request STUDENT Epic access is ADDED to your current profile.

Consent

I understand that the APP Center reserves the right to charge an Administrative Fee for rotations to students who are not UNCH employees.

Rotation Start Date*

List the start date of the requested rotation

Rotation End Date*

List the date of the end of the rotation

Number of hours needed*

List the number of hours needed during this rotation

Describe Rotation Requested*

Be as specific as possible. Describe the rotation type (primary care, acute care, critical care, etc..), patient population (adults, peds, lifespan, etc,,,) setting (inpatient, outpatient clinic) and any specialties permitted or requested. IF you are seeking a specific clinic or unit, please list (for example, must be an ICU but have already completed a rotation in the CVTICU)

Course rotation is associated with*

Describe the course that this rotation is required for. Elaborate on where this course falls in your rotation timeline compared to where you are in your program (Example: this is my 2nd rotation of 3 required acute care rotations in my program. I have already completed a cardiology and emergency medicine rotation)

Preceptor Credentials*

Your placement request MUST be for a preceptor who is a NP or PA. Please note that MD, DO and LCSWs are NOT preceptors with the APP Center. DESCRIBE the type of APP preceptor your program allows (NP and/or PA) and list any additional qualifications required by your program. Please list the specific type of APP preceptor required if your program has any restrictions on the specific type of APP permitted (Example: "Preceptor must have at least 6 months experience and must be a AGACNP - NO other type of NP or PA preceptors are permitted by my program")

Specific preceptor requested?

Are you requesting a specific person to precept you? (Note: most requests are NOT for a specific person).

No
Yes

Potential preceptor's name and location

List the name and clinic/unit location of the preceptor you are requesting (IF you are requesting a specific person).

Describe any communications with potential preceptor*

IF a potential preceptor has offered to precept you, provide details of discussion including how and when you communicated with this preceptor. IF you have not had any communications, list NONE.

NAME of School Placement Coordinator*

List the name and title of contact person for coordinating the placement

Email address of Placement Coordinator*

List the email address of your Placement Coordinator

Name of School Compliance Coordinator*

List the name and title of the contact person for compliance documentation. If this is the same as the Placement Coordinator, list them again

Email address of School Compliance Coordinator*

List the email address of the Point of Contact for Compliance matters. This person MUST be available to respond promptly to compliance inquiries, especially when TJC survey teams are onsite at UNC-Hospitals

Compliance Phone*

List the phone number of the Point of Contact for Compliance matters. This person MUST be available to respond promptly to compliance inquiries, especially when TJC survey teams are onsite at UNC-Hospitals

Name of the Point of Contact at your school for Clinical Affiliation Agreement*

List the name and title of the contact person for clinical affiliation agreements (contracts). If this is the same as the Placement or Compliance Coordinator, list them again

Email address of Clinical Affiliation Agreement Point of Contact

List the email address of the Point of Contact for contract related matters

Name of person completing this form

List the name of the person who completed this Request Application Form (and title of school representative if school completed the form)

First Last Title

Email address of person completing this Request Application Form*

List the email address of the person who completed this form

Application Form – NP, CNM, DNP, MSN, SRNA and SAA Students

NP, CNM, DNP, MSN, CAA and CRNA Student APP Rotation Request Application