To request a clinical placement, complete this fillable online form. Do not submit this form until you have secured a preceptor who has agreed to work with you, and you have all the information needed to complete the form. The form must be complete to submit. 

Submitting this form does not guarantee that the agency or the preceptor will be approved. If the student plans to work with multiple preceptors and agencies, a separate form for each must be submitted. For the best learning experience, students will want to limit to no more than 2 preceptors/agencies in the same semester. Students are not approved to see patients or log any clinical time without a contract that has been approved by the university and program faculty. 

If you have any questions or technical difficulties in completing this form contact the School of Nursing at 785-670-1533.

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