{"id":3921,"date":"2021-08-07T23:22:11","date_gmt":"2021-08-08T03:22:11","guid":{"rendered":"https:\/\/www.med.unc.edu\/app\/?page_id=3921"},"modified":"2023-07-03T00:29:24","modified_gmt":"2023-07-03T04:29:24","slug":"visiting-pa-student-rotation-application","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/app\/app-student-rotations\/visiting-pa-student-rotations\/visiting-pa-student-rotation-application\/","title":{"rendered":"Application Form &#8211; Visiting PA Student Rotation"},"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_3' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Visiting PA Student Rotation Request Application<\/h2>\n                            <p class='gform_description'>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.<\/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'  id='gform_3'  action='\/app\/wp-json\/wp\/v2\/pages\/3921\/' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_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_3_49'>Instagram<\/label><div class='ginput_container'><input name='input_49' id='input_3_49' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_49'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_3_40\" 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\"  >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.<\/div><fieldset id=\"field_3_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_3_1'>Enter PA student's full legal name.  If student does 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_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_3_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_3_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_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_3_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_3_45'>Enter today's date<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_3_45' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_45_date_format gfield_description_3_45\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_45_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_45' class='gform_hidden' value='https:\/\/www.med.unc.edu\/app\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_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_3_2'>Student Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_2'>Enter PA student's school email address<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_3_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_3_2\" \/>\n                        <\/div><\/div><fieldset id=\"field_3_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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' >Student PROGRAM (Visiting PA)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_44'>Check the box to indicate your Advanced Practice Area of study<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_44'><div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='PA'  id='choice_3_44_1'   aria-describedby=\"gfield_description_3_44\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>PA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='CAA'  id='choice_3_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_2' id='label_3_44_2' class='gform-field-label gform-field-label--type-inline'>CAA<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_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_3_3'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_3'>Enter PA student's phone number<\/div><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_3_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_3_3\"  \/><\/div><\/div><div id=\"field_3_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_3_4'>University<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_4'>Enter school name<\/div><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='small'  aria-describedby=\"gfield_description_3_4\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_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_3_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_3_5'>Enter PA student's 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_3_5' type='text' value='' class='small'  aria-describedby=\"gfield_description_3_5\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_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' >Is student 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_3_22'>Select yes if PA student is a CURRENT UNC Health employee<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_22'><div class='gchoice gchoice_3_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_3_22_1'   aria-describedby=\"gfield_description_3_22\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_22_1' id='label_3_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_3_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_3_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_22_2' id='label_3_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_3_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_3_23'>If employee, list UNC Health entity and unit\/clinic<\/label><div class='gfield_description' id='gfield_description_3_23'>Describe where student currently works and role.  For example, student is a RN at UNCMC on L&amp;D<\/div><div class='ginput_container ginput_container_text'><input name='input_23' id='input_3_23' type='text' value='' class='small'  aria-describedby=\"gfield_description_3_23\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_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_3_24'>UNC Health Email<\/label><div class='gfield_description' id='gfield_description_3_24'>List student's UNC Health email address<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_24' id='input_3_24' type='email' value='' class='small'     aria-invalid=\"false\" aria-describedby=\"gfield_description_3_24\" \/>\n                        <\/div><\/div><div id=\"field_3_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_3_25'>UNC Health EMPLOYEE Epic access<\/label><div class='gfield_description' id='gfield_description_3_25'>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.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_3_25' class='textarea small'  aria-describedby=\"gfield_description_3_25\" maxlength='150'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_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_3_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_3_26'>List the start date of the requested rotation<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_26' id='input_3_26' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_26_date_format gfield_description_3_26\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_26_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_26' class='gform_hidden' value='https:\/\/www.med.unc.edu\/app\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_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_3_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_3_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_3_27' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_27_date_format gfield_description_3_27\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_27_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_27' class='gform_hidden' value='https:\/\/www.med.unc.edu\/app\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_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_3_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_3_28'>List the number of hours needed during this rotation<\/div><div class='ginput_container ginput_container_number'><input name='input_28' id='input_3_28' type='number' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_3_28\" \/><\/div><\/div><div id=\"field_3_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_3_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_3_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 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)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_3_19' class='textarea medium'  aria-describedby=\"gfield_description_3_19\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_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_3_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_3_21'>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......)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_3_21' class='textarea medium'  aria-describedby=\"gfield_description_3_21\" maxlength='350'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_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_3_7'>Preceptor Credentials<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_7'>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.<\/div><div class='ginput_container ginput_container_text'><input name='input_7' id='input_3_7' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_7\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_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' >Has a potential preceptor already been identified?<\/legend><div class='gfield_description' id='gfield_description_3_30'>Has a potential preceptor already been identified\/expressed an interest in precepting you?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_30'>\n\t\t\t<div class='gchoice gchoice_3_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_3_30_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_3_30\"   \/>\n\t\t\t\t\t<label for='choice_3_30_0' id='label_3_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_3_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_3_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_30_1' id='label_3_30_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_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_3_32'>Potential preceptor&#039;s name and location<\/label><div class='gfield_description' id='gfield_description_3_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_3_32' class='textarea small'  aria-describedby=\"gfield_description_3_32\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_46\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_46'>Describe any communications with potential preceptor<\/label><div class='gfield_description' id='gfield_description_3_46'>IF a potential preceptor has offered to precept you, provide details of discussion including how and when you communicated with this preceptor. <\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_3_46' class='textarea small'  aria-describedby=\"gfield_description_3_46\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_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_3_29'>NAME of PA\/CAA School Placement Coordinator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_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_3_29' type='text' value='' class='small'  aria-describedby=\"gfield_description_3_29\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_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_3_34'>Email address of PA\/CAA Placement Coordinator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_34'>List the email address of your Placement Coordinator<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_34' id='input_3_34' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_3_34\" \/>\n                        <\/div><\/div><div id=\"field_3_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_3_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_3_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_3_33' type='text' value='' class='small'  aria-describedby=\"gfield_description_3_33\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_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_3_35'>Email address of Compliance Coordinator<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_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_3_35' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_3_35\" \/>\n                        <\/div><\/div><div id=\"field_3_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_3_37'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_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_3_37' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_3_37\"  \/><\/div><\/div><fieldset id=\"field_3_38\" 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 contact person for Clinical Affiliation Agreement<\/legend><div class='gfield_description' id='gfield_description_3_38'>List the name and title of the Point of Contact at your school  for matters pertaining to the clinical affiliation agreement.<\/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_3_38'>\n                            \n                            <span id='input_3_38_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_38.3' id='input_3_38_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_38_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_38_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_38.6' id='input_3_38_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_38_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_3_38_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_38.8' id='input_3_38_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_38_8' class='gform-field-label gform-field-label--type-sub '>Title<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_3_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_3_39'>Email address of Clinical Affiliation Agreement Point of Contact<\/label><div class='gfield_description' id='gfield_description_3_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_3_39' type='email' value='' class='small'     aria-invalid=\"false\" aria-describedby=\"gfield_description_3_39\" \/>\n                        <\/div><\/div><fieldset id=\"field_3_41\" 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' >Name and Title of Visiting PA\/CAA School Faculty or Staff completing this request<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_41'>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.<\/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_3_41'>\n                            \n                            <span id='input_3_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.3' id='input_3_41_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_41_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_41_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.6' id='input_3_41_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_41_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_3_41_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.8' id='input_3_41_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_41_8' class='gform-field-label gform-field-label--type-sub '>Title<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><div id=\"field_3_42\" 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_3_42'>Email address of PA\/CAA School representative who completed this form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_3_42'>List the email address of the person who completed this form<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_42' id='input_3_42' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_3_42\" \/>\n                        <\/div><\/div><fieldset id=\"field_3_43\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_43.1' id='input_3_43_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_43\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_43_1' >Administrative Fee<\/label><input type='hidden' name='input_43.2' value='Administrative Fee' class='gform_hidden' \/><input type='hidden' name='input_43.3' value='5' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_43' tabindex='0'>I understand that the APP Center reserves the right to charge an Administrative Fee for Visiting PA\/CAA Student rotations.<\/div><\/fieldset><div id=\"field_3_47\" class=\"gfield gfield--type-post_title gfield--input-type-post_title field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_47'>Post Title<\/label><div class='ginput_container ginput_container_post_title'>\n\t\t\t\t\t<input name='input_47' id='input_3_47' type='text' value='' class='large'    aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div><\/div><div id=\"field_3_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_3_48'>CAPTCHA<\/label><div id='input_3_48' class='ginput_container ginput_recaptcha' data-sitekey='6Le3_hkUAAAAAF4TV5mQhdPRwUKnVkvFanDTTuGs'  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