BETTY WHITE HEALTH CENTER
The Kentucky State University School of Nursing offers a RN-B.S.N. program for registered nurses. The program of study includes practicum experiences designed to meet personal and professional goals. The RN, under the guidance of the course faculty, selects a practicum site for the course-related experiences.
___ RN, in NUR ___ and
Instructor, is requesting approval to complete a
practicum experience or observation experience or internship in the___ area
of your facility during the
semester.
The student and preceptor [if warranted] will mutually determine the specific dates and times of this experience. Knowledge of the institution's requirements (e.g. clearances, liability insurance, CPR, HIPAA, etc.) are the responsibility of the student. The student is responsible for obtaining necessary compliances and providing necessary proof to the agency.
I request that the ___Agency approve the practicum experience. I understand that I am responsible for meeting the institution's requirements (e.g. professional liability insurance, clearances, and CPR, etc.) and providing proof of compliances, if requested.
Student _____ Date _____
Please complete the following: We agree to permit the aforementioned student to complete a practicum experience in our facility. We understand that we may terminate this agreement at any time for poor performance or unprofessional conduct by the student.
Director or Administrator_____ Date_____
Title ___
Preceptor___ Date___
Title
Course Instructor ___ Date ___
Adopted: 05/18
Revised 06/23