Application Form - Visiting PA Student Rotation | Advanced Practice Provider Center

Visiting PA Student Rotation Request Application

Rotations MUST originate from the Visiting PA program clinical faculty/staff in order to ensure that the rotation has been approved by the Visiting PA program. PA School personnel must complete this form to place a Visiting PA student ELECTIVE rotation request for a clinical rotation at UNC Hospital/SOM Clinics. NOTE: This form is NOT for rotations at UNC Rex or UNCPN. Rex and UNCPN are separate entities and should be contacted separately.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Limited opportunities for clinical year rotations are available to students from Visiting PA programs for ELECTIVE rotations. Visiting PA students CANNOT complete CORE rotations at UNC Hospital/SOM Clinics.

Full LEGAL Name*

Enter PA student's full legal name. If student does 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 PA student's school email address

Student PROGRAM (Visiting PA)*

Check the box to indicate your Advanced Practice Area of study

CAA

Phone Number*

Enter PA student's phone number

University*

Enter school name

Expected Graduation Date (enter month and year)*

Enter PA student's expected date of graduation using this format: Month and yyyy (e.g. May 2023)

Is student a UNC Health employee?*

Select yes if PA student is a CURRENT UNC Health employee

Yes

If employee, list UNC Health entity and unit/clinic

Describe where student currently works and role. For example, student is a RN at UNCMC on L&D

UNC Health Email

List student's UNC Health email address

UNC Health EMPLOYEE Epic access

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

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 specialty. 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 student's rotation timeline compared to where student is in their program (Example: this is student's 1st elective rotation in the program. Student has already completed the following rotations......)

Preceptor Credentials*

Describe the type of preceptor your program requires (NP, PA, MD, DO) and list any additional qualifications required by your program. Example: Preceptor must have at least 6 months of experience and must be a PA, MD or DO only.

Has a potential preceptor already been identified?

Has a potential preceptor already been identified/expressed an interest in precepting you?

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.

NAME of PA/CAA School Placement Coordinator*

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

Email address of PA/CAA 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 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

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 contact person for Clinical Affiliation Agreement

List the name and title of the Point of Contact at your school for matters pertaining to the clinical affiliation agreement.

First Last Title

Email address of Clinical Affiliation Agreement Point of Contact

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

Name and Title of Visiting PA/CAA School Faculty or Staff completing this request*

List the name and title of the Visiting PA/CAA School representative who is placing this request. NOTE: Rotations MUST originate from the Visiting PA/CAA program clinical faculty/staff in order to ensure that the rotation has been approved by the Visiting PA/CAA program.

First Last Title

Email address of PA/CAA School representative who completed this form*

List the email address of the person who completed this form

Post Title

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Application Form – Visiting PA Student Rotation

Visiting PA Student Rotation Request Application