University* Enter the name of your school
Expected Graduation Date (enter month and year)* Enter your expected date of graduation using this format: Month and yyyy (e.g. May 2023)
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 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.
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")
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
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
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