NUR 330/460 Practicum Experience Request
Sign in to Google to save your progress. Learn more
Email *
Please enter your first name. *
Please enter your last name. *
Please enter your Student ID number starting with 700. *
Please enter your Delaware Tech email address. *
Which class are you registered in for summer 2024? (Note: students will be notified when requests are being accepted for future semesters) *
At what agency would you like to complete your practicum experience? Please see the list of current agencies used by the program for availability and special instructions. 

Note: If your requested agency is not on the list of current agencies used by the program, please enter the agency's name, city, and state.
 *
Did you use this agency previously for an RN to BSN practicum experience? (example: completed hours for NUR 330 at the agency)
 *
Are you currently an employee of this agency? *
Which department, unit, school, or area of interest would you like to use? *
Please enter your requested preceptor's name and credentials (example: Alex Smith, BSN, RN). 

If you are still securing a preceptor, please do not submit the form at this time.

If you are approved to complete practicum at PAM Rehab or Public Health, please enter TBD. 
 *
Please enter your requested preceptor's work email. 

If you are still securing a preceptor, please do not submit the form at this time.

If you are approved to complete practicum at PAM Rehab or Public Health, please enter TBD.
 *
Please check the box to acknowledge the following:

Completing this form does not clear students to start practicum hours. After all pre-practicum requirements are complete, students will be notified when they have program clearance for their experience per the instructions on the RN to BSN Resources Weebly practicum page. In addition, hours may not start before the first day of the semester.

Students are responsible for adhering to these terms as well as the information on the Weebly and in the RN to BSN Student Handbook.
 *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Delaware Technical Community College. Report Abuse
Google Forms