{"id":3576,"date":"2021-08-04T23:25:53","date_gmt":"2021-08-05T03:25:53","guid":{"rendered":"https:\/\/www.med.unc.edu\/app\/?page_id=3576"},"modified":"2023-07-03T00:31:21","modified_gmt":"2023-07-03T04:31:21","slug":"app-nursing-student-rotation-application","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/app\/app-student-rotations\/app-nursing-student-rotations\/app-nursing-student-rotation-application\/","title":{"rendered":"Application Form &#8211; NP, CNM, DNP, MSN, SRNA and SAA Students"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">NP, CNM, DNP, MSN, CAA and CRNA Student APP Rotation Request Application<\/h2>\n                            <p class='gform_description'>NP, DNP, CNM, MSN, CAA and CRNA students must complete this form to place a 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.<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/app\/wp-json\/wp\/v2\/pages\/3576\/#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_49\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_49'>X\/Twitter<\/label><div class='ginput_container'><input name='input_49' id='input_2_49' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_49'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_2_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Visiting PA students must NOT use this application form. \nVisiting PA students must complete their rotation requests on the Visiting PA Rotation Request Application found on the APP Center Visiting PA student webpage.<\/div><fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full LEGAL Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_1'>Enter your full legal name.  If you do NOT have a middle name, enter n\/a in the middle name field<\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_2_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_2_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_45\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_45'>Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_45'>Enter today's date<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_2_45' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_45_date_format gfield_description_2_45\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_45_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_45' class='gform_hidden' value='https:\/\/www.med.unc.edu\/app\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_2'>Student Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_2'>Enter your school email address<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_2_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_2\" \/>\n                        <\/div><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_3'>Enter your phone number<\/div><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_2_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_3\"  \/><\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>University<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_4'>Enter the name of your school<\/div><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='small'  aria-describedby=\"gfield_description_2_4\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Program<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_10'>Use the drop down to select the program you are enrolled in at your school<\/div><div class='ginput_container ginput_container_select'><select name='input_10' id='input_2_10' class='medium gfield_select'  aria-describedby=\"gfield_description_2_10\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Nurse Practitioner Program (NP)' >Nurse Practitioner Program (NP)<\/option><option value='Doctor of Nursing Practice (DNP)' >Doctor of Nursing Practice (DNP)<\/option><option value='Certified Nurse Midwife Program (CNM)' >Certified Nurse Midwife Program (CNM)<\/option><option value='MSN (Health Care Administration, Leadership, Education, Informatics, Outcomes Management)' >MSN (Health Care Administration, Leadership, Education, Informatics, Outcomes Management)<\/option><option value='Student Registered Nurse Anesthetist (SRNA)' >Student Registered Nurse Anesthetist (SRNA)<\/option><option value='Student Anesthesiologist Assistant (SAA)' >Student Anesthesiologist Assistant (SAA)<\/option><option value='OTHER' >OTHER<\/option><\/select><\/div><\/div><fieldset id=\"field_2_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Advanced Practice Area<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_12'>Check the box to indicate your Advanced Practice Area of study.  If you are dual-enrolled, select BOTH boxes to indicate both practice areas.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_12'><div class='gchoice gchoice_2_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='AGACNP'  id='choice_2_12_1'   aria-describedby=\"gfield_description_2_12\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_1' id='label_2_12_1' class='gform-field-label gform-field-label--type-inline'>AGACNP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='AGPCNP'  id='choice_2_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_2' id='label_2_12_2' class='gform-field-label gform-field-label--type-inline'>AGPCNP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='CNM'  id='choice_2_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_3' id='label_2_12_3' class='gform-field-label gform-field-label--type-inline'>CNM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='ENP'  id='choice_2_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_4' id='label_2_12_4' class='gform-field-label gform-field-label--type-inline'>ENP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='FNP'  id='choice_2_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_5' id='label_2_12_5' class='gform-field-label gform-field-label--type-inline'>FNP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='MSN HCA, Informatics, Leadership'  id='choice_2_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_6' id='label_2_12_6' class='gform-field-label gform-field-label--type-inline'>MSN HCA, Informatics, Leadership<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.7' type='checkbox'  value='NNP'  id='choice_2_12_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_7' id='label_2_12_7' class='gform-field-label gform-field-label--type-inline'>NNP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.8' type='checkbox'  value='PMHNP'  id='choice_2_12_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_8' id='label_2_12_8' class='gform-field-label gform-field-label--type-inline'>PMHNP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.9' type='checkbox'  value='PNP'  id='choice_2_12_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_9' id='label_2_12_9' class='gform-field-label gform-field-label--type-inline'>PNP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.11' type='checkbox'  value='PNP-AC'  id='choice_2_12_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_11' id='label_2_12_11' class='gform-field-label gform-field-label--type-inline'>PNP-AC<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.12' type='checkbox'  value='WHNP'  id='choice_2_12_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_12' id='label_2_12_12' class='gform-field-label gform-field-label--type-inline'>WHNP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.13' type='checkbox'  value='SAA'  id='choice_2_12_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_13' id='label_2_12_13' class='gform-field-label gform-field-label--type-inline'>SAA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.14' type='checkbox'  value='SRNA'  id='choice_2_12_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_14' id='label_2_12_14' class='gform-field-label gform-field-label--type-inline'>SRNA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_12_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.15' type='checkbox'  value='OTHER'  id='choice_2_12_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_15' id='label_2_12_15' class='gform-field-label gform-field-label--type-inline'>OTHER<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is this a Post-Graduate Certificate Program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_16'>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<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_16'>\n\t\t\t<div class='gchoice gchoice_2_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_2_16_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_16\"   \/>\n\t\t\t\t\t<label for='choice_2_16_0' id='label_2_16_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_2_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Expected Graduation Date (enter month and year)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_5'>Enter your expected date of graduation using this format:  Month and yyyy (e.g. May 2023)<\/div><div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='small'  aria-describedby=\"gfield_description_2_5\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you a UNC Health employee?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_2_22'>Select yes if you are a CURRENT UNC Health employee<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_22'><div class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='No'  id='choice_2_22_1'   aria-describedby=\"gfield_description_2_22\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Yes'  id='choice_2_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_2' id='label_2_22_2' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_23\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_23'>If employee, list UNC Health entity and unit\/clinic<\/label><div class='gfield_description' id='gfield_description_2_23'>Describe where you currently work and your role.  For example, I am a RN at UNCMC on L&amp;D<\/div><div class='ginput_container ginput_container_text'><input name='input_23' id='input_2_23' type='text' value='' class='small'  aria-describedby=\"gfield_description_2_23\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_24\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>UNC Health Email<\/label><div class='gfield_description' id='gfield_description_2_24'>List your UNC Health email address<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_24' id='input_2_24' type='email' value='' class='small'     aria-invalid=\"false\" aria-describedby=\"gfield_description_2_24\" \/>\n                        <\/div><\/div><div id=\"field_2_25\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>UNC Health EMPLOYEE Epic access<\/label><div class='gfield_description' id='gfield_description_2_25'>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.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_2_25' class='textarea small'  aria-describedby=\"gfield_description_2_25\" maxlength='150'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_44\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_44.1' id='input_2_44_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_44_1' >I understand that the APP Center reserves the right to charge an Administrative Fee for rotations to students who are not UNCH employees.<\/label><input type='hidden' name='input_44.2' value='I understand that the APP Center reserves the right to charge an Administrative Fee for rotations to students who are not UNCH employees.' class='gform_hidden' \/><input type='hidden' name='input_44.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_26\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'>Rotation Start Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_26'>List the start date of the requested rotation<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_26' id='input_2_26' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_26_date_format gfield_description_2_26\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_26_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_26' class='gform_hidden' value='https:\/\/www.med.unc.edu\/app\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_27\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_27'>Rotation End Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_27'>List the date of the end of the rotation<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_27' id='input_2_27' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_27_date_format gfield_description_2_27\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_27_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_27' class='gform_hidden' value='https:\/\/www.med.unc.edu\/app\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>Number of hours needed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_28'>List the number of hours needed during this rotation<\/div><div class='ginput_container ginput_container_number'><input name='input_28' id='input_2_28' type='number' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_28\" \/><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>Describe Rotation Requested<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_19'>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) <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_2_19' class='textarea medium'  aria-describedby=\"gfield_description_2_19\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_21\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_21'>Course rotation is associated with<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_21'>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)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_2_21' class='textarea medium'  aria-describedby=\"gfield_description_2_21\" maxlength='350'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Preceptor Credentials<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_7'>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\")<\/div><div class='ginput_container ginput_container_text'><input name='input_7' id='input_2_7' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_7\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Specific preceptor requested?<\/legend><div class='gfield_description' id='gfield_description_2_30'>Are you requesting a specific person to precept you?  (Note: most requests are NOT for a specific person).<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_30'>\n\t\t\t<div class='gchoice gchoice_2_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_2_30_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_30\"   \/>\n\t\t\t\t\t<label for='choice_2_30_0' id='label_2_30_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_2_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'>Potential preceptor&#039;s name and location<\/label><div class='gfield_description' id='gfield_description_2_32'>List the name and clinic\/unit location of the preceptor you are requesting (IF you are requesting a specific person).  <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_2_32' class='textarea small'  aria-describedby=\"gfield_description_2_32\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_47\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'>Describe any communications with potential preceptor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_47'>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.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_2_47' class='textarea small'  aria-describedby=\"gfield_description_2_47\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_29'>NAME of School Placement Coordinator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_29'>List the name and title of contact person for coordinating the placement<\/div><div class='ginput_container ginput_container_text'><input name='input_29' id='input_2_29' type='text' value='' class='small'  aria-describedby=\"gfield_description_2_29\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_34\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_34'>Email address of Placement Coordinator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_34'>List the email address of your Placement Coordinator<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_34' id='input_2_34' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_34\" \/>\n                        <\/div><\/div><div id=\"field_2_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_33'>Name of School Compliance Coordinator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_33'>List the name and title of the contact person for compliance documentation.  If this is the same as the Placement Coordinator, list them again<\/div><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='small'  aria-describedby=\"gfield_description_2_33\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_35\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_35'>Email address of School Compliance Coordinator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_35'>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 <\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_35' id='input_2_35' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_35\" \/>\n                        <\/div><\/div><div id=\"field_2_37\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'>Compliance Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_37'>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 <\/div><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_2_37' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_37\"  \/><\/div><\/div><div id=\"field_2_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_46'>Name of the Point of Contact at your school for Clinical Affiliation Agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_46'>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<\/div><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='small'  aria-describedby=\"gfield_description_2_46\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_39\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_39'>Email address of Clinical Affiliation Agreement Point of Contact<\/label><div class='gfield_description' id='gfield_description_2_39'>List the email address of the Point of Contact for contract related matters<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_39' id='input_2_39' type='email' value='' class='small'     aria-invalid=\"false\" aria-describedby=\"gfield_description_2_39\" \/>\n                        <\/div><\/div><fieldset id=\"field_2_42\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of person completing this form<\/legend><div class='gfield_description' id='gfield_description_2_42'>List the name of the person who completed this Request Application Form (and title of school representative if school completed the form)  <\/div><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_2_42'>\n                            \n                            <span id='input_2_42_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.3' id='input_2_42_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_42_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_42_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.6' id='input_2_42_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_42_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_2_42_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.8' id='input_2_42_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_42_8' class='gform-field-label gform-field-label--type-sub '>Title<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_2_43\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_43'>Email address of person completing this Request Application Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_2_43'>List the email address of the person who completed this form<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_43' id='input_2_43' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_43\" \/>\n                        <\/div><\/div><div id=\"field_2_48\" class=\"gfield gfield--type-captcha gfield--input-type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_48'>CAPTCHA<\/label><div id='input_2_48' class='ginput_container ginput_recaptcha' data-sitekey='6Le3_hkUAAAAAF4TV5mQhdPRwUKnVkvFanDTTuGs'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input 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