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)
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 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.
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.
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
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